Kidneys - DKA, HHNS, AKI Flashcards
What is DKA?
- Absence of insulin
- Leads to disorders of metabolism of carbohydrates, proteins and fat
What are the three clinical features of DKA?
- Hyperglycaemia
- Dehydration and electrolyte loss
- Acidosis
What does DKA stand for?
- Diabetic ketoacidosis
What does HHNS stand for?
Hyperosmolar Hyperglycemic Nonketotic Syndrome
What is HHNS?
- Lack of effective insulin leading to hypersmolarity and hyperglycemia
- Causes osmotic diuresis resulting in water and electrolyte losses
What are the characteristics of DKA?
- Type I diabetes
- Omission of insulin, physiological stress
- Rapid onset less than 24 hours
- BGL >13.9 mmol/L
- Arterial pH <7.3
- Present serum and urine ketones
- Serum osmolatity of 300-350 mmol/L
- Plasma bicarbonate <15 mmol/L
- Elevated urea and creatinine levels
- Mortality rate <5%
What are the characteristics of HHNS?
- Type II diabetes
- Physiological stress
- Slow onset (days)
- BGL >33.3 mmol/L
- Normal arterial pH
- Absent serum and urine ketones
- Serum osmolatity >350 mmol/L
- Normal plasma bicarbonate
- Elevated urea and creatinine levels
- Mortality rate 10-40%
What are the precipitating factors?
- ↑ amounts of stress hormone:
- Infection, myocardial infarction, surgery
- New diabetics
- Management errors in insulin doses
- Deliberate omission of insulin by patient
- Erratic compliance with insulin and eating
- Recreational drug use/ alcohol binges
What are the signs and symptoms of DKA?
- Fatigue, headache
- Polyurina
- Polydipsia
- Polyphagia
- Nausea and vomiting
- Abdominal pain
- Dehydration
- Kussmaul respirations
- Acetone on breath
- Decreased LOC
What are the nursing assessments taken for DKA and HHNS?
- LOC
- ABC
- ABGs
- Dehydration assessment
- Signs of hypokalemia
- Potential for hypovolemic shock
- Signs of infection
What are the signs of hypokalaemia?
- Fatigue
- Muscle weakness, leg cramps, soft, flabby muscles
- Nausea and vomiting, paralytic ileus
- Paraesthesia, decreased reflexes
- Weak, irregular pulse
- Polyuria
- Hyperglycaemia
- ECG changes: ST segment depression, flattened T wave, presence of U wave, Ventricular arrhythmias, bradycardia
What are some nursing interventions for DKA and HHNS?
- Monitoring of vital signs, LOC, ECG, O2 saturations, urine output – 1/24
- Monitor FBC 1/24
- Monitor serum glucose and potassium
What is rehydration therapy?
- 1L 0.9% saline over 1 hour
- 1L over 1-2 hours
- 2 L over 4 hours
- 1L every 4-6 hours
- Switch to 5-10% glucose over next 8 hours once BGL <15mmol/L
- Continue with saline in addition to glucose if patient remains volume depleted
How is insulin administrated?
- 50 units actrapid in 50ml NaCl in syringe driver for IV infusion
- Start 6 unit/hour
- Laboratory venous BGL should be checked 2/24
How much potassium choride is added to each litre of fluid depending on the serum potassium levels?
- > 5.5 = Nil recheck in 2 hours
- 3.5-5.5 = 20 mmol/L
- 3.0-3.4 = 40 mmol/L
- <3.0 = Higher rates of potassium should be administered in ICU
What are some important factors to potassium replacement?
- Don’t add potassium chloride to the first litre of fluid administered
- Establish potassium levels
- Monitor potassium levels every 2 hours
When should sliding scale insulin be stopped?
When insulin and ketone levels are normal
How to prevent DKA?
- Seek prompt medical treatment – antibotics/ paracetamol
- Cough mixtures should be sugar-free
- In unable to eat normally – carbohydrates should be replaced with cereals, soups or liquid carbs
- Drink plenty of sugar-free liquids
- If vomiting – seek medical attention
- Insulin should be continues even if not eating
- It is likely that insulin doses will need to increased during illness
- BGL should be checked more regularly (4x/day)
What is AKI?
- Characterised by rapid onset and rapid loss of kidney function
- Accompanied by a rise in serum creatinine and/ or reduction in urine output
- Potentially reversible – but has high mortality rate
- Usually affects people with life threatening conditions
- Commonly follows severe, prolonged hypotension or hypovolaemia or exposure to nephrotoxic agent
What are the common prerenal causes of AKI?
- Hypovolaemia
- Decreased cardiac output
- Decreased peripheral vascular resistance
- Decreased renovascular blood flow
What are the common intrarenal causes of AKI?
- Nephrotoxic injury
- Interstitial nephritis
- Other – acute tubular necrosis
What are the common postrenal causes of AKI?
- Benign prostatic hyperplasia
- Bladder cancer
- Calculi formation
- Neuromuscular disorders
- Prostrate cancer
- Spinal cord disease
- Strictures
- Trauma
What is acute tubular necrosis?
- Nephrotoxic or ischemic injury that damages renal tubular epithelium
- ATN most common cause of intrarenal failure especially in hospitalized patients.
- Damage to cellular structure:
- Prevents normal concentration of urine
- Filtration of wastes
- Regulation of acid-base, electrolyte and water balance
What is RIFLE used for?
The classification of acute renal failure
What does RIFLE stand for?
R - risk I - injury F - failure L - loss E - end-stage kidney disease
What is the MDT care for acute renal failure?
- Treat precipitating cause
- Fluid restriction (600 mls + previous 24 hours loss)
- Nutritional therapy (enteral nutrition)
- Measures to lower potassium
- Calcium supplements
- Dialysis
What nursing management is undertaken for acute renal failure?
- Monitor vital signs
- Fluid and electrolyte balance
- Urine assessment
- Respiratory assessment
- Skin assessment
- Prevent infection
- Monitor fatigue and potential anxiety
- Monitor of complications – arrhythmias, infection
What are the general principles of dialysis?
- Diffusion
- Osmosis
- Ultrafiltration
What is the RIFLE criteria for risk of acute renal failure?
- Increased creatinine x 1.5 or GFR decreases >25%
- UO <0.5 ml kg-1 h-1x6hr
What is the RIFLE criteria for risk of injury of acute renal failure?
- Increased creatinine x 2 or GFR decrease >50%
- UO <0.5 ml kg-1 h-1x12hr
What is the RIFLE criteria for acute renal failure?
- Increased creatinine x 3 or GFR decrease >75% or creatinine >4 mg per 100 ml (acute rise of >0.5 mg per 100 ml)
- UO <0.3 ml kg-1 h-1x24hr or anuria x 12hr
What is the RIFLE criteria for loss?
- Persistent ARF - complete loss of renal function >4 weeks
What is the RIFLE criteria for end-stage kidney disease?
- End-stage renal disease
What is collaborative management aiming to do?
- Treating hyperglycemia
- Correcting dehydration and hypovolemia
- Correcting electrolyte loss
- Correcting acidosis
- Identify and correct the precipitating cause
What to check for in DKA and HHNS?
- Hourly vital signs
- Consider CVP monitoring if clinical evidence of poor LV or renal function
- Consider NG tube if drowsy or vomiting and in severe cases of DA as gastroparesis may be present
- Hypothermia may be present in admission - hourly temperature recording required
- Give oxygen if paO2 below 8ommHg (11kPa)
- Check urine ketones twice daily
What laboratory monitoring is needed in the first 24 hours of DKA?
- Glucose
- Sodium, potassium chloride and urea
- Creatinine
- Bicarbonate
- Arterial gas
What is the normal potassium levels?
3.5 - 5.2 mmol/L
What are some nephrotoxic drugs?
- Gentamicin
- Vancomycin
- MI contrast
What are the phases of AKI?
- Initial or onset phase (hours too days)
- Oliguric or maintenance phase ( 1-7 days or longer)
- Diuretic phase (7-14 days, can last up to 3 weeks)
- Recovery phase (months to years)
What is TPN?
- Total parenteral/peripheral nutrition - nutrients are given that bypasses the digestive system (through a vein)
What is PPN?
- Partial parenteral nutrition - intravenous administration of nutrients
What to check for in a drain bag?
- Color
- Clarity
- Mucous shreds
- Weight
