Exam 3: Renal Failure (Acute Renal Failure/Acute Kidney Injury) Flashcards
What is the general definition of acute kidney failure?
Rapid reduction in kidney function. Within hours or days.
What shit gets fucked up when you have acute kidney failure?
→ Fluid and electrolyte balance
→ Acid-Base balance
→ Unable to get rid of toxins
What is azotemia?
Build up of nitrogenous waste
What is something that automatically puts you at high risk of going into acute kidney failure in the hospital?
Being in the hospital!
Reduced perfusion = ____________ failure.
PRERENAL
What are some causes of prerenal failure?
→ Shock
→ Hypotension
→ Anything that blocks blood flow to kidneys (Atherosclerosis)
Kidney damage = _________ failure.
INTRARENAL
What are some issues that can cause intrarenal failure?
→ Glomerulonephritis
→ Lupus
→ Drugs that damage to the kidney
→ Lupus
→ Toxins
→ Ischemia
What are just a few drugs that can cause damage to the kidneys?
→ IV contrast
→ Abx – Vanc!
→ NSAIDS
Obstruction = ___________ failure.
POSTRENAL
What are some causes of postrenal failure?
→ Bladder Cancer
→ Kidney Stones
→ Prostate cancer or BPH
Three ways kidneys compensate with AKF?
→ Activating RAAS system
→ Constricting kidney blood vessels
Raise pressure
→ Releasing ADH
Hold onto fluid → perfusion
All the ways kidneys compensate are grea! Do they increase/decrease blood volume?Increase/decrease kidney perfusion?
They also cause:
Increase, increase.
→ Oliguria
→ ADH causes less urination
→ → Azotemia (build-up of nitrogenous waste)
Oliguria =?
(how many ml/day)
Less than 400 mL/24 hours
Kidney failure is number one reason _______ patients die (name of disease)
Lupus
What is one of the big clues that there is AKI?
Oliguria
What lab value is one of the best indicators of AKI?
Creatinine
Per Iggy: The serum creatinine level does not increase until 50% of the kidney function is lost, so ANY level of serum creatinine values is important.
What is a normal BUN?
10 - 20
(Remember: This is measuring the effectiveness of kidney excretion of urea nitrogen, a by-product of protein breakdown in the liver)
What is a normal serum creatinine (Mary isn’t allowed to answer this)?
Normal < 1.2
You will see abnormal electrolytes with AKI. Will the K+ and Na be high or low?
High K+, high Na
If patients are still urinating, what is likely happening?
Filtration problem
What are some other diagnostic tests to confirm AKI?
→ Ultrasound
→ CT Scans (no IV contrast)
→ MRI
→ X-ray/ KUB (kidney, ureter, and bladder x-ray)
Name 3 early signs of AKI:
→ Low UOP (less than 30mL/hr)
→ Edema
→ Rising creatinine
What do we want to maintain our MAP at?
MAP > 65
If you are not seeing urine in the collection bag, what should you do?
Check the foley/line for kinks
What is one of the main meds we will use first when we confirm AKI?
Diuretics
Most people with AKI don’t get__________ and don’t even get a ______________.
Dialysis, renal consult
Acute kidney injury outcomes:
About __% of patients with AKI will not recover kidney function.
10%
What happens in end stage renal disease (general)?
→ Will require long term dialysis and/or transplant
→ Will require long term dialysis access
Your patient has a history of hypertension and is admitted for hypertensive crisis. He is on a nicardipine drip with parameters to keep the blood pressure below 180/100. Currently, your patient’s blood pressure is 96/58 and the drip is running at 25mg/hr. You notice that your patient’s urinary output is 80 mL over the last four hours. After reducing the rate of the nicardipine drip, what is your next priority action?
A) Check the patency of the foley catheter
B) Call rapid response
C) Call the provider
D) Give the patient a bolus of NS
A) Check the patency of the foley catheter
ALSO: Provider should have given bottom parameters – don’t be afraid to ask for them!
Why do we need to be careful with patients with HTN and AKI?
The patient lives at that high BP level. Then we give BP meds and they can’t perfuse (prerenal failure!)
Describe the basics of CKD (3):
→ Progressive
→ Irreversible
→ Leads to end stage kidney disease
What are the stages of CKD based on?
Glomerular Filtration Rate
What is a normal GFR?
125 ml/min totaling 180 L/day
Google says 90 to 120 mL/min/1.73 m2
Quick throwback question: How is GFR controlled in the body?
Per Iggy: By selectively constricting and dilating the afferent and efferent arterioles. When systolic pressure drops below 65 - 70 mm Hg, these self regulation processes do not maintain GFR.
What is the GFR for stage 1 CKD?
Normal GFR!
They just have an increased risk for kidney damage
Name 3 diseases that have this highest risk factors, thus are stage 1:
HTN, Lupus, DM
Describe stage 2 CKD. What is the GFR?
Mild disease/ decrease in kidney function/ mild decrease in GFR (60-89)
Describe stage 3 CKD. What is the GFR?
Moderate disease/Azotemia present/ Restriction of fluids/ GFR (30-59)
Describe stage 4 CKD. What is the GFR?
Severe disease/ cannot maintain A-B and F-E balance/ Dialysis may be needed/ GFR (15-29)
Describe stage 5 CKD. What is the GFR?
GFR < 15/ Dialysis or death/ Transplant?
At what stage do we begin treating CKD?
Stage 3
Re: Blood cells. What do kidneys contribute?
Help make red blood cells (erythropoietin!). When they are damaged this can cause anemia.
Once __% of function is gone, kidneys unable to maintain urine production and maintain homeostasis
75%
When a majority of the function is gone, what happens to the BUN and urine production (up? down?)?
→ BUN rises
→ Urine production decreases
With CKD do patients become acidotic or alkalotic? Why?
Acidotic. Acid excretion is decreased. NOT related to DKA.
What kind of respiratory compensation will we see?
Kussmaul breathing
Increased phosphorus lends to decreased ___________.
Calcium
What causes itchy skin in CKD?
Uric acid build up
Hyperkalemia or hypokalemia?
Hyperkalemia
What cardiac issues will we see with CKD?
→ Hypertension
→ Malfunction of RAAS system
→ Hyperlipidemia
→ Heart failure
→ Pericarditis
→ Cardiomyopathies
What GI issues will we see with CKD?
→ Uremia leads to stomatitis
→ Colitis
→ BUN/Creatinine- anorexia, nausea, vomiting
→ Hiccups
→ PUD
The build up in uric acid in the system can alter a patients’ __________.
Taste
WTF is uremic halitosis?
Breath smells like urine
What s/s will we see if FVO?
→ Crackles
→ JVD
→ Edema
This is a list of more SE you will see with CKD:
→ Weight loss
→ Anorexia
→ Nausea & vomiting
→ Fatigue
→ Drowsiness
→ Confusion → Seizures and coma
→ Neuropathies
→ Edema
→ Hypertension
→ Dysrhythmias
→ Respiration rate and depth
→ Bleeding issues
→ Skeletal changes (risk for fractures)
What skin changes will you possibly see with CKD?
→ Pruritus
→ Bronzed color
→ Uremic frost
→ Bruises
What is a huge assessment that is extra important to include with CKD?
Psychosocial
Patient nutrition education: They should eat high/low potassium food on dialysis?
Low
Patient nutrition education: More or less Na when on dialysis?
More!
Let’s go over these electrolyes again:
Na → high/low?
K+ → high/low?
Ca → high/low?
Phos → high/low?
Na → HIGH
K+ → HIGH
Ca → LOW
Phos → HIGH
A goal of care is that patients will not gain (or lose) more than
____ lbs overnight
____ lbs in a week
2 lbs overnight
5 lbs in a week
These meds are used to:
Increase urinary elimination of fluid
Reduces fluid overload
Reduces blood pressure
Diuretics
Are diuretics typically used once dialysis is started?
No!
Throwback to pharm: What do we want to monitor for with furosemide (side effect)?
Ototoxicity
What med can actually slow the progression of CKD?
ACE inhibitors (prils!)
How do calcium channel blockers help CKD?
Improve GFR & blood flow to kidneys
How do beta blockers help CKD?
Help increase cardiac output/ avoid heart failure (reduced perfusion of kidneys → accelerated kidney disease)
Nutrition fun: Reduced_________ can preserve kidney function.
Protein
How much protein should they have a day?
0.55-0.60 g/kg/day
Protein should be increased/decreased once patient starts dialysis? To how much?
Increased, 1-1.2 g/kg/day
What are fluid restrictions based on?
Based on urinary output
What are the potassium restrictions with CKD (how much can they have?)?
60-70 mEq/day
Amount of sodium allowed per day?
1-3 g/day
Sodium should be increased/decreased once patient starts dialysis? To how much?
Increased, 2-4 g/day
How do we restrict phosphorus?
Phosphate binders given with meals
What are some nursing interventions with CKD?
→ Infection prevention
→ Injury prevention
→ Be aware of medications that are cleared by the kidneys
* May need dose adjustment
* May have increased effects
→ High risk of fatigue → rest and activity balance
→ Anxiety reducing techniques
Name 3 types of renal replacement therapy:
→ Peritoneal Dialysis
→ Hemodialysis
→ Continuous renal replacement therapy
What is an AV-fistula?
Surgical connection of artery and vein
What are the most common sites used for AV fistulas?
Radial, brachial, or cephalic
AV fistulas increase venous blood flow to ________ mL/min.
250-400mL/min
Feel the _________, and listen for the_________.
Thrill, bruit
At what stage to we begin the conversation about dialysis? Why?
Stage 4
→ Maturation of the fistula takes a while.
How long does it take for the fistula to mature?
6 months
What is used as alternative to fistula?
AV graft (synthetic)
Fistula care:
→ No blood pressures or venipunctures on fistula extremity
→ Hang a sign over bed
→ Feel for a thrill and listen for a bruit every four hours
→ LIGHTLY put stethoscope on it
→ Assess distal pulses
→ Assess for signs of infection
→ Avoid placing pressure on fistula extremity
What is the most common fistula complication?
Thrombosis
→ tPA can be used to dissolve clot
What do we do for fistula strictures?
Balloon angioplasty
Do you use sterile or clean technique when accessing a fistula?
Sterile
HIGH RISK
What happens when we get ischemia (reduced arterial blood flow below fistula)?
Must get a new fistula
Describe a VasCath:
→ Non-tunneled
*INFECTION RISK
→ Large Bore Central Line
*INFECTION RISK
→ Intended for short-term use
What is a PermCath?
→ Same as a vascath but tunnel
→ Takes longer to put in, has to be in IR
VasCath/PermCath Care/Complications
→ Infection
Sterile Access
Sterile dressing changes
→ Misplacement/ Dislodgement
Only use femoral site if absolutely necessary
Do not use for anything other than dialysis
unless its an emergency
→ Bleeding
How does peritoneal dialysis work?
Utilizes peritoneal cavity for exchange of fluids, wastes and electrolytes
_____ L fluid infused into abdomen during peritoneal dialysis.
1-2
What does the fluid drained from peritoneal dialysis contain?
Contains excess fluid, electrolytes, wastes
Benefits of peritoneal dialysis:
Very flexible scheduling
Can be performed at home
→ But have to do several times a day
Managed by patient
Less diet restrictions
May be temporary until fistula matures
Works well for older adults
Drawbacks of peritoneal dialysis:
Slower than hemodialysis
Loss of protein occurs
Uncomfortable (fluid infused into peritoneal)
Can cause peritoneal injury
Not an option for extensive abdominal surgery/ adhesions
Over time, fibrosis may occur (peritoneal membrane)
PD complications (there are a lot)?
Infection
Peritonitis
→ Cloudy
Brown: Bowel perf
Red: Bleeding
Avoid by utilizing sterile technique
Ensure catheter is not leaking
Monitor for cloudy outflow/ effluent **
Abdominal tenderness
Fever
Discomfort
Warm bags
Infuse slowly
Bowel Perforation
Brown effluent
What is the most commonly prescribed renal replacement therapy?
Hemodialysis
Is hemodialysis continuous or intermittent?
Intermittent dialysis
→ Usually 3 days a week
What happens during hemodialysis?
Passes patient’s blood through artificial semipermeable membrane to filter and excrete (to mimic kidneys)
Can you do hemodialysis at home?
Requires medical and nursing care to administer
What is calciphylaxis?
Vascular calcification and skin necrosis
How is it determined if someone needs hemodialysis? What labs is it based on and what have we tried first?
Based on GFR, uremia, fluids, and electrolyte imbalance.
→ When patient has had no response to
diuretics
→ Symptomatic Hyperkalemia
* No after how much diuretics we give, it’s
not helping
→ Calciphylaxis (vascular calcification and
skin necrosis)
→ Ingestion of toxins that requires dialysis for
removal
With hemodialysis, molecules move from an area of _____ concentration (blood) to a ____ concentration (dialysate)
High, low
Dialysate and blood are flowing in ________ directions across semipermeable membrane
Opposing
_____ and ____ move from blood to dialysate.
_____ and _____ move from dialysate to blood.
*Electrolytes/ions
Potassium and Na
Bicarb and calcium
Describe nursing care with hemodialysis (there are a lot, just give it a try):
Involves 3 4-hour treatments per week
May be more as CKD progresses
Warming (patients get hypothermic)
Monitor often
Often fatigued after/ Changes in LOC
Risk for seizures
Large volume shifts → Risk for hemodynamic instability
We are removing huge volumes of fluid!
Be aware of psychosocial issues
Large volume shifts give us a risk for hemodynamic instability. What can happen with this (bad thing)?
Cardiac arrest
What is “Dialysis for the unstable patient”?
Continuous Renal Replacement Therapy
When is Continuous Renal Replacement Therapy utilized?
Utilized for acute lung injury or when patient with CRF is hemodynamically unstable
CRRT is performed where?
In an ICU
How does CRRT work?
Hemofiltration
Uses a filter with fine pores (unlike HD’s diffusion process)
CRRT avoids ______________ with hemodialysis but provides the same result.
lLrge volume shifts
