Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease

Question 1

kidney function of urinary ELIMINATION includes

Answer 1

excretion of waste, FLUID AND ELECTROLYTE BALANCE, regulation of ACID–BASE BALANCE, and hormone secretion.

Question 2

Kidney function loss also interrupts the activity of every organ system, particularly:

Answer 2

the immune, endocrine, skeletal, and cardiovascular systems.

Question 3

When kidney function is permanently or persistently impaired, as with end-stage kidney disease (ESKD) what treatment is needed

Answer 3

dialysis or kidney transplant is a life-saving approach for urinary ELIMINATION to maintain homeostasis, FLUID AND ELECTROLYTE BALANCE, and ACID–BASE BALANCE.

Question 4

When kidney function declines gradually:

Answer 4

most of the nephrons must be destroyed before kidney injury is obvious.

Question 5

Acute kidney injury(AKI)

Answer 5

is a rapid reduction in kidney function resulting in a failure to maintain FLUID AND ELECTROLYTE BALANCE and ACID–BASE BALANCE.

• AKI occurs over a few hours or days.
• During this time of decreased renal function, the patient is at increased risk because of the stress on remaining nephrons.

Question 6

causes of AKI are

Answer 6

reduced PERFUSION to the kidneys, damage to kidney tissue, and obstruction.

Question 7

(coagulopathy)

Answer 7

reduce perfusion, cause inflammation and direct tissue damage, and create obstruction of urinary flow. Thus, coagulopathy is a pre-renal, intrarenal, and post-renal cause of AKI.

Question 8

When renal decline is sudden, the functioning nephrons:

Answer 8

are overworked, and kidney failure may develop with the loss of only 50% of functioning nephrons.

Question 9

acute effects what vs chronic effects what

Answer 9

Acute failure affects many systems, while chronic disease affects every body system.

Question 10

Pre-renal failure

Answer 10

is caused by reduced PERFUSION to the kidneys, such as in hypovolemic shock and heart failure.

oManifestations include hypotension, tachycardia, decreased urine output, decreased cardiac output, decreased central venous pressure, and lethargy.

Question 11

critical rescue nursing priority AKI

Answer 11

Because reduced PERFUSION from volume depletion is a common cause of AKI, prevention of volume depletion and early intervention

Question 12

Reversal of AKI

Answer 12

especially with prompt intervention by correcting blood volume and improving kidney PERFUSION, increasing blood pressure, and improving cardiac output.

fluid challenges often used to promote kidney perfusion

Question 13

Intrarenal or intrinsic renal failure is caused by

Answer 13

inflammation, INFECTION, and damage from toxins that cause intracellular changes of the tubular system in kidney tissue.

Question 14

Intrarenal or intrinsic renal failure s/s

Answer 14

oliguria or anuria, edema, hypertension, tachycardia, shortness of breath, distended neck veins, elevated central venous pressure, weight gain, respiratory crackles, anorexia, nausea, vomiting, lethargy or changes in levels of consciousness, and electrocardiographic changes.

Question 15

When kidney function declines: first phase

Answer 15

the oliguric phases of AKI begin. However, not all patients with AKI experience oliguria.

Question 16

after the oliguric phase

Answer 16

diuretic phase, in which hypovolemia and electrolyte losses are the main problems.

Question 17

The longer the period oliguria or anuria ___

Answer 17

the less likely the patient will return to baseline kidney function

Question 18

Inflammation causes of AKI can result in

Answer 18

polyuria.

Question 19

The plan of care AKI

Answer 19

focuses on fluid and electrolyte replacement and monitoring. Onset of polyuria can be the start of recovery from AKI.

Question 20

Because kidney function is unstable in AKI, continuously monitor ___

Answer 20

intake and output and serum electrolyte levels to determine how the supplementation affects FLUID AND ELECTROLYTE FUNCTION.

Question 21

Post-renal azotemia develops from ___

Answer 21

obstruction to the outflow of formed urine anywhere within the kidney or urinary tract.

Question 22

azotemia

Answer 22

biochemical abnormality, defined as elevation, or buildup of, nitrogenous products

Question 23

AKI expect to see what labs

Answer 23

rising blood urea nitrogen and serum creatinine and abnormal blood electrolyte values.

Question 24

AKI usually do not have the anemia associated with chronic failure unless

Answer 24

there is hemorrhagic blood loss or high blood urea level.

Question 25

Contrast: Adequate hydration is essential to

Answer 25

prevent contrast-induced nephropathy. IV fluids are often given to high risk patients before the procedure to ensure hydration, dilution of the contrast medium, and speed urinary ELIMINATION.

Question 26

Renal biopsy is performed if

Answer 26

the cause is uncertain, immunologic disease is suspected, or the reversibility of the kidney failure needs to be determined.

Question 27

AKI therapy

Answer 27

Drug therapy, diet therapy, and renal replacement therapy, such as peritoneal dialysis, hemodialysis, or hemofiltration, are commonly used for management.

Question 28

CKD

Answer 28

When kidney function declines gradually, it is diagnosed as chronic kidney disease(CKD), also known as chronic renal failure. progressive, irreversible kidney injury and affects every body system.

Question 29

acute-on-chronic kidney injury,

Answer 29

CKD with AKI can accelerate loss of kidney function. Low numbers of functioning nephrons from CKD contribute to the progression of kidney dysfunction.

Question 30

End stage kidney disease

Answer 30

When kidney function cannot sustain life, it becomes ESKD.

Question 31

uremia

Answer 31

(azotemia with symptoms)

Question 32

CKD with greatly reduced GFR causes many problems, including

Answer 32

abnormal urine production, severe disruption of FLUID AND ELECTROLYTE BALANCE, and metabolic abnormalities.

Question 33

Because healthy nephrons become larger and work harder:

Answer 33

urine production and water ELIMINATION are sufficient to maintain essential homeostasis until about three fourths of kidney function is lost.

Question 34

(isosthenuria)

Answer 34

As the disease progresses, the ability to produce diluted urine is reduced, resulting in urine with a fixed osmolarity

Question 35

Kidney damage raises systemic blood pressure, which:

Answer 35

also increases glomerular pressure and damage to remaining unaffected nephrons.

Question 36

kidney damage increases the workload on the heart as a result of anemia, hypertension, and fluid overload.

Answer 36

heart failure may occur Cardiac disease is the leading cause of death in patients with end-stage failure.

Question 37

urine changes in CKD

Answer 37

The amount and composition of the urine change as kidney function decreases. oThe actual urine output varies according to remaining kidney function. oOliguria is usually seen with severe CKD or ESKD, but some patients can produce 1 L or more daily. oDaily urine volume usually changes again after dialysis is started. oA long duration of oliguria is an indication that recovery of kidney function is not to be expected.

Question 38

urine changes in CKD

Answer 38

The amount and composition of the urine change as kidney function decreases. oThe actual urine output varies according to remaining kidney function. oOliguria is usually seen with severe CKD or ESKD, but some patients can produce 1 L or more daily. oDaily urine volume usually changes again after dialysis is started. oA long duration of oliguria is an indication that recovery of kidney function is not to be expected.

Question 39

Long-standing hypertension

Answer 39

is a risk for CKD and rapid progression of kidney failure once CKD occurs. Therefore blood pressure control is essential in preserving kidney function.

Question 40

CKD causes extreme changes in laboratory values, including

Answer 40

creatinine, blood urea nitrogen, sodium, potassium, calcium, phosphate, bicarbonate, hemoglobin, and hematocrit. urinalysis is performed and 24-hour urine specimen is sent.

Question 41

Injury prevention strategies are needed because

Answer 41

patients may have brittle, fragile bones that fracture easily and cause minimal pain

Question 42

Problems with calcium and phosphorus levels can result in

Answer 42

renal osteodystrophy, metastatic calcifications, and cardiovascular disease.

Question 43

renal osteodystrophy

Answer 43

currently defined as an alteration of bone morphology in patients with chronic kidney disease (CKD)

Question 44

metastatic calcifications

Answer 44

the pathological process whereby calcium salts accumulate in previously healthy tissues

Question 45

Drug therapy with diuretics is prescribed for

Answer 45

patients with some kidney impairment to manage fluid retention or help control blood pressure.

Question 46

Protein

Answer 46

is restricted on the basis of reduced glomerular filtration rate (GFR) and the severity of the symptoms.

Question 47

uremia which can result in severe pruritus (itching) is caused by?

Answer 47

Buildup of waste products from protein breakdown.

Question 48

Uremic frost,

Answer 48

a layer of urea crystals from evaporated sweat, may appear on the face, eyebrows, axillae, and groin in patients with advanced uremic syndrome.

Question 49

When patients cannot be managed with conservative therapies, such as diet, drugs, and fluid restriction:

Answer 49

dialysis is indicated

Question 50

Daily weight

Answer 50

Instruct patients to weigh themselves daily, keep a daily log, and report any daily weight gain of 2 pounds or more immediately to the health care provider. In addition to fluid balance, weight is affected by the inability to ingest, digest, or absorb food and nutrients

Question 51

Neurologic symptoms of CKD and uremic syndrome vary and if untreated:

Answer 51

encephalopathy can lead to seizures and coma Dialysis is used emergently when neurologic problems result from CKD Depression may compound cognitive and neurologic problems

Question 52

Candidates for transplantation must be

Answer 52

free of medical problems that might increase the risks from the procedure

Question 53

Kidney donors

Answer 53

may be living donors related or unrelated to the patient, non-heart-beating donors, and cadaveric donors. * Organs from living related donors have the highest rates of kidney graft survival—90%. * Physical criteria for donors include absence of systemic disease and infection and adequate kidney function as determined by diagnostic studies

Question 54

complications that are possible after transplantation

Answer 54

including rejection, acute tubular necrosis, thrombosis of the major blood vessels, vascular leakage or thrombosis (both of which require emergency nephrectomy), and wound problems, such as hematomas, abscesses, lymphoceles, and infection. •Teach patients on immunosuppressive therapy to assess themselves daily for fever, general malaise, and nausea or vomiting.

Question 55

Renal replacement therapy (RRT)

Answer 55

will remove nitrogenous wastes and re-establish FLUID AND ELECTROLYTE BALANCE, as well as restore ACID–BASE BALANCE.

Question 56

Immediate RRT is indicated for

Answer 56

fluid overload (compromising tissue PERFUSION) not responding to diuretics (including fluid overload with pericarditis), symptomatic hyperkalemia,calciphylaxis, and symptomatic toxin ingestion, such as drug overdose or alcohol poisoning that is dialyzable

Question 57

or CKD, RRT is needed when

Answer 57

the pathologic changes of stage 4 and stage 5 CKD are life threatening or pose continuing discomfort.

Question 58

hemodialysis for CKD is started when:

Answer 58

uremic manifestations, such as nausea and vomiting, decreased attention span, decreased cognition, and pruritus, are present.

Question 59

fatigue

Answer 59

common and often profound problem among patients with CKD, particularly among patients receiving dialysis.

Question 60

fistula or graft

Answer 60

Avoid taking blood pressure measurements or drawing blood from an arm with an arteriovenous (AV) fistula or graft, and do not use the AV fistula or graft site to give IV fluids or draw blood.

Question 61

heparinization during the hemodialysis procedure

Answer 61

can increase the risk for bleeding, teach the patient to avoid all invasive procedures within 4 to 6 hours after hemodialysis. Monitor for signs of hemorrhage.

Question 62

The patient is at risk for infection due to

Answer 62

skin breakdown, IMMUNITY-related kidney dysfunction, or malnutrition.

Question 63

dialysis and antihypertensives

Answer 63

Use caution when giving an antihypertensive before a scheduled dialysis treatment; some short-acting antihypertensives can contribute to hypotension during dialysis.

Question 64

access site complications

Answer 64

thrombosis or stenosis, infection, aneurysm formation, ischemia, and heart failure.

Question 65

peritoneal dialysis PD

Answer 65

allows exchanges of wastes, fluids, and electrolytes to occur in the peritoneal cavity, but is slower than hemodialysis.

Question 66

Automated peritoneal dialysis (APD)

Answer 66

may be used in the acute care setting, the outpatient dialysis center, or the patient’s home. APD uses a cycling machine for dialysate inflow, dwell, and outflow according to preset times and volumes.

Question 67

Continuous-cycle peritoneal dialysis (CCPD)

Answer 67

is a form of automated dialysis that uses an automated cycling machine. Exchanges occur at night while the patient sleeps. The final exchange of the night is left to dwell through the day and is drained the next evening as the process is repeated. CCPD offers the advantage of 24-hour dialysis, as in APD, but the sterile catheter system is opened less often

Question 68

PD complications

Answer 68

Peritonitis, or infection and inflammation of the peritoneal cavity, is the major complication, commonly from connection site contamination. bleeding, which is expected when the catheter is first placed, and bowel perforation, which is serious

Question 69

critically ill patients tx

Answer 69

Continuous renal replacement therapies in the form of hemofiltration are often better tolerated than hemodialysis for critically ill patients because this method avoids rapid shifts of fluids and electrolytes.

Question 70

acute failure dialysis type

Answer 70

Continuous AV hemofiltration and continuous AV hemodialysis and filtration

Question 71

type of dialysis for patients who have fluid volume overload, are resistant to diuretics, and have unstable blood pressures and output

Answer 71

Continuous AV hemofiltration

Question 72

Post-dialysis care includes

Answer 72

closely monitoring the patient for hypotension, headache, nausea, vomiting, dizziness, and muscle cramps.