Chapter 48: Management of Patients w/ Kidney Disorders Flashcards
Fluid Volume Overload
Fluid intake exceeds the ability of the kidneys to excrete fluid
Clinical Manifestations of Fluid Volume Overload
Acute weight gain ≥5%
Edema
Crackles, SOB
Decreased BUN, decreased hematocrit
Distended neck veins
General Management Strategies of Fluid Volume Overload
Fluid and sodium restriction, diuretic agents, & dialysis
Fluid Volume Deficit
If fluid intake is inadequate, the patient is said to be volume depleted
Clinical Manifestations of Fluid Volume Deficit
Acute weight loss ≥5%
Decreased skin turgor, dry mucous membranes
Oliguria or anuria
Increased hematocrit
BUN level increased out of proportion to creatinine level
Hypothermia
General Management Strategies for Fluid Volume Deficit
Fluid challenge, fluid replacement orally or parenterally
Clinical Manifestations of Hyponatremia
Nausea
Malaise, lethargy
Headache
Abdominal cramps
Apprehension, seizures
General Management Strategies for Hyponatremia
Diet, NS or hypertonic saline solutions
Clinical Manifestations of Hypernatremia
Dry, sticky mucous membranes, thirst, rough dry tongue, fever, restlessness, weakness, disorientation
General Management Strategies for Hypernatremia
Fluids, diuretic agents, dietary restriction
Clinical Manifestations of Hypokalemia
General Management Strategies for Hyperkalemia
Clinical Manifestations of Hypocalcemia
General Management Strategies for Hypocalcemia
Clinical Manifestations of Hypercalcemia
General Management Strategies for Hypercalcemia
Clinical Manifestations of Metabolic Acidosis
General Management Strategies for Metabolic Acidosis
Clinical Manifestations of Metabolic Alkalosis
General Management Strategies for Metabolic Alkalosis
Clinical Manifestations of Hypoalbuminemia
General Management Strategies for Hypoalbuminemia
Intake & Output (I & O) Record
Used to document important fluid parameters, including the amount of fluid taken in (orally or parenterally), the volume of urine excreted, and other fluid losses (diarrhea, vomiting, diaphoresis)
What is a more accurate depiction of a patient’s volume status: I & O record or daily weights?
Daily weights
1 kg weight gain is = ?
1-kg wt gain = 1 L (1000mL) retained fluid
Gerontological Considerations for Patients w/ Kidney Disorders
With aging, kidney is less able to respond to acute fluid & electrolyte changes
Fluid Balance Deficit in Older Adults Can Lead To:
- Falls
- Med toxicity
- Constipation
- UTI and respiratory tract infections
- Delirium
- Seizures
- Electrolyte imbalances
- Hyperthermia
- Delayed wound healing
Chronic Kidney Disease (CKD)
Umbrella term that describes kidney damage or decrease in glomerular filtration rate (GFR) lasting for 3 or more months
End-Stage Kidney Disease (ESKD)
Final stage of CKD
Results in retention of uremic waste products & need for renal replacement therapy
Risk Factors for CKD
Cardiovascular disease, diabetes, HTN, & obesity
Acute Kidney Injury
Damage to the kidney’s cause a rapid loss of renal function
- Inability to filter waste or perform regulatory functions
Pre-Renal Acute Kidney Injury
Interrupted blood flow, poor blood flow, or absent blood flow to the kidneys (acute/chronic)
Causes of Prerenal AKI
Severe Life-Threatening Dehydration
Hypotension
Sepsis
Shock
Massive hemorrhagic event
Over diuresis (volume depletion)
Heart failure
Cirrhosis
Bilateral renal artery stenosis
Nephrosclerosis
Nephrosclerosis
Hardening/narrowing of the renal arteries-> leads to slow, progressive kidney damage
- Via long-standing, poorly controlled HTN
DM can also cause this
Asymptomatic early in disease course
Uremia results in patients if dialysis is not initiated
Renal Artery Stenosis (RAS)
Narrowing of the renal arteries
- Usually the result of atherosclerosis
Tubulointerstitial Nephritis (TIN)
Inflammation that affects the tubules of the kidneys and the tissues that surround them
Postrenal AKI
Severe, sudden obstruction of urine to the ureters
Causes of Postrenal AKI
Benign prostatic hypertrophy or prostate cancer
Cervical cancer
Retroperitoneal disorders
Intratubular obstruction (crystals or myeloma light chains)
Pelvic mass or invasive pelvic malignancy
Bladder masses (clot, tumor or fungus ball)
Neurogenic bladder
Urethral strictures
Kidney stones
Obstructive Disorders
Stasis of urine, leading to infection or stone formation
Progressive dilation of renal collecting ducts and tubular structures, causing destruction and scarring
Can come from: any obstruction of urine (kidney stones, scar tissue, strictures, pregnancy, tumors, congenital defects, prostate)
Nephrolitiasis
Characterized by an acute, sudden pain in the back or side that radiates to the lower abdomen and groin
Stage 1 of Chronic Kidney Disease (CKD)
GFR equal to or >90 mL/min
Kidney damage w/ normal or increased GFR
Stage 2 of Chronic Kidney Disease (CKD)
GFR= 60–89 mL/min
Mild decrease in GFR
Stage 3 of Chronic Kidney Disease (CKD)
GFR= 30–59 mL/min
Moderate decrease in GFR
Stage 4 of Chronic Kidney Disease (CKD)
GFR= 15–29 mL/min
Severe decrease in GFR
Stage 5 of Chronic Kidney Disease (CKD)
GFR <15 mL/min
End-stage kidney disease or CKD
Clinical Manifestations of CKD
Anemia (decreased erthyropoeitin)
Metabolic acidosis
Abnormal calcium & phosphorous balance
Fluid retention
- Edema & congestive HF can develop
HTN
Glomerular filtration rate (GFR)
Amount of plasma filtered through the glomeruli per unit of time
Diagnosis Criteria for Acute Kidney Injury
50% or greater increase in baseline serum creatinine
Medical Management of CKD
Treat underlying causes
Keep BP below 125 to 130/80 mmHg
Control cardiovascular risk factors
Treat hyperglycemia
Manage anemia
Encourage smoking cessation
Weight loss & exercise
Reduce salt & alcohol intake
Nephrosclerosis
Hardening of renal arteries
Pathophysiology of Nephrosclerosis
Damage is caused by decreased blood flow to the kidneys-> patchy necrosis of the renal parenchyma
- Over time, fibrosis occurs & glomeruli are destroyed
- Can progress quickly over time if not treated
- Acute: Associated w/significant & prolonged HTN
Glomerulonephritis
Inflammation of the glomerular capillaries that can occur in acute & chronic forms
The importance in early Diagnosis of Acute Kidney Injury
Mortality rate is 10-80%
Can progress to ESKD if not treated quickly
Clinical Aspects of Acute Kidney Injury
Changes to BUN, Cr, and GFR
Metabolic complications such as acidosis and fluid/electrolyte imbalances
Urine output (UO) volume may or may not be affected
Patient may appear critically ill showing signs of lethargy, drowsiness, headache, muscle twitching, seizures
Initiation Phase of Acute Kidney Injury
Begins at initial insult to kidney function & ends when the oliguria phase starts
Oliguria Phase of Acute Kidney Injury
Increase of serum concentration of substances usually excreted by kidneys (ex – creatinine, K+, phos, mag)
UO drops to 400ml/day or less
Watch for uremic symptoms, life threating electrolyte imbalances such as hyperkalemia may also develop
Diuresis Phase of Acute Kidney Injury
Gradual increase in GFR and UO, stabilization of labs with possible decrease
-Continue to monitor for uremic symptoms and for possible dehydration
Recovery Phase of Acute Kidney Injury
Labs return close to patient baseline; permanently decreased
- GFR will be present (1-3%)
Acute Kidney Injury Causes
Volume depletion
Impaired cardiac function
- LT sided HF (decreased perfusion to kidneys)
- Low EF
Urinary tract obstructions
- Kidney stones
Vasodilation
Infections
Increased diuresis (physiological or medication)
Renal ischemia (transfusion reactions or hemolytic anemia; rhabdomyolysis, trauma/crushing injuries)
Nephrotic agents (NSAIDS, ACE inhibitors, chemicals,
contrasts, etc…)
Comorbidities (Diabetes is present in ~40% of AKI cases)
https://thekidneyexperts.com/kidneys-dont-work/
Acute Kidney Injury Treatment
Eliminate/treat the underlying cause
Manage fluid balance and avoid fluid excess
Provide renal replacement therapy (RRT) when indicated
HD; PD; CRRT (will learn about these in Complex Health)
Strict asepsis, infection prevention with all catheters and vascular access
devices
Nursing Actions for Acute Kidney Injury
Assess/monitor daily weights, CVP, blood and urine labs, electrolyte levels – especially hyperkalemia
I/O balance
Total UO per 24 hrs
BP and patient assessment
Aseptic techniques
Patient education and psychosocial support
