T3 Kidney Injury Flashcards
When kidney function is impaired it affects what organ systems
Fluid and electrolyte balance
Acid base balance
Urinary elimination
Excretion of waste
Hormone secretion
Most common in acute care settings
What happens in acute kidney injury?
Can result in death but full recovery is possible
When it gets to what? high mortality rate occurs
Rapid reduction in kidney function resulting in failure to maintain fluid and electrolyte balance and acid–base balance
Dialysis
Labs to watch for in AK
Main complications
Increase of creatinine 1.5 times or more from baseline in 48 hours*
u/o less than 0.5ml/kg/hr for 6 hours*
Occurs over a few hours or days
Causes systemic effects and complications( (table 68-3)**
Main complications- metabolic acidosis, hyperkalemia, fluid overload, heart failure
High mortality if renal replacement is needed but good prognosis if kidney function is maintained
Can progress to ?
The longer patient is oliguric or anuric the less likely the patient will ?
CKD
return to full function
Causes of AKI
Reduced perfusion to kidneys, damage to kidney tissue,
obstruction of urine outflow*
Conditions that result in AKI*—see Table 68-4
Prerenal causes
Instrinsic causes
Postrenal causes
More likely in hospitalized adults with advanced age or pre-existing conditions
Damage is done from compensatory mechanisms
Constricting blood vessels, activating RAA Pathway and release of ADH increase blood volume
RAA= renin angiotensin aldosterone pathway
These also lead to oliguria (<400 ml/day urine) and azotemia (build up of nitrogenous wastes in blood)*
Loose ability to repair itself
Prerenal causes of aki?
dehydration, hypovolemic shock, hypotension, renal artery stenosis, NSAID use (decreases renal plasma flow and disrupts vasodilation in glomeruli)
Anything that causes reduced perfusion to kidneys outside
Intrarenal causes of aki
glomerulonephritis, embolism in kidney, pyelonephritis, Nephrotoxic substances (table 68-5) ** meds hard on kidneys
68-4
Postrenal causes of aki
bladder cancer, kidney stones, prostate cancer
Obstructs urine outflow
The nurse is assessing a patient with a diagnosis of prerenal AKI. Which condition would the nurse expect to find in the patient’s recent history?
A: Pyelonephritis
B: Myocardial infarction
C: Bladder cancer
D: Kidney stones
B. MI
Health promotion and maintenance
What equals better outcome for pt?
Avoid dehydration by doing what?
Characteristic changes to report/monitor?
What drugs to avoid?
Labs to monitor?
Be alert to potential AKI!
Early interventions equal better outcomes for patient*
Avoid dehydration by drinking 2 to 3 L of water daily*
Be aware of urine characteristic changes
Accurately measure i/o
Report oliguria after two hours*
Avoid nephrotoxic substances (table 68-5)
Monitor lab values: BUN, Creatinine, Potassium, osmolarity, urine spec gravity*
AKI hx to obtain ?
History: medical, medications, risk factors
Urine characteristic changes or obstructive problems- ask what color it is and how often they urinate a day
Recent surgery or trauma-be aware of hypovolemic shock or anything that could reduce perfusion
Drug history
Coexisting conditions
Acute illnesses (immunity-mediated AKI)- intrarenal
Anticipate AKI after hypotension or shock
What to asses in kidney injury
Physical assessment
-Hourly urine output
(Watch if urine output is decreased)
Assess for fluid overload*
If kidneys are not functioning we are retaining fluid
Evaluate vital signs for hypoperfusion and hypoxemia*
A patient with acute kidney injury has a blood pressure of 76/55 mm Hg. The healthcare provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The patient is starting to develop shortness of breath. What is the nurse’s priority action?
a: calculate the mean arterial pressure
B: ask for insertion of a pulmonary artery catheter
C: take the patient’s pulse
D: slow down the normal saline infusion
D: slow down the normal saline infusion
Fluid overload, stop fluid, reality to provider that you did and receive next orders
Diagnostic assessment in AKI
Laboratory assessment* Creatinine, BUN Electrolyte values Serum Osmolarity Urinalysis
Imaging assessments-
US, CT, x-rays (pelvis, kidneys, KUB), MAG3
Imaging can help find cause of obstruction or injury- (can see tumors or kidney stones)
Other diagnostic assessments
Kidney biopsy-Biopsy done if cause is unknown: look for immune mediated or other diseases
Interventions for AKI
Drug therapy?
Nutrition?
Avoid hypotension, maintain fluid balance*
Reduce exposure to nephrotoxic agents
Frequently monitor laboratory values
Closely watch I/O*
Drug therapy: diuretics, fluid challenges,
Nutrition: AKI has high rate of protein breakdown. Dietician to assess protein and calorie needs.
Diet with specific protein, sodium and fluid levels.
Possible restricted potassium Nutrition therapy*, daily weights
Kidney replacement therapy (intermittent versus continuous)* (aka dialysis)
Kidney replacement therapy
Indications for it?
What does it do?
What is the cause?
Types?
When AKI is due to drugs or other toxins, RRT (Renal replacement therapy)can remove toxins
Indications: loss of kidney function, inadequate waste elimination*
- Symptomatic uremia (decline in cognitive function)
- Rapidly rising potassium (> 6.5 meq/l)
- Metabolic acidosis (severe; ph less than 7.1)
- Fluid overload that inhibits perfusion
Intermittent Kidney Replacement
Outpatient vs inpatient
Dialysate helps remove unwanted waste products via diffusion
3-4 times weekly
Requires anticoagulation
Creates large fluid shifts*
AV fistula graft
Check for what to assess patency?
Monitor for what?
No Bp on which arm ?
- Check for bruit and thrill to assess patency
- Monitor signs of infection
- No BP or IV on that arm(restricted extremity)
(Bruit- hear whooshing noise
Thrill- feel (rush of fluid)
Siliconized rubber catheter placed into abdominal cavity for infusion of dialysate
Peritoneal Dialysis (PD)*
Types of PD? (selection depends on patient’s ability and lifestyle)
Continuous ambulatory
Multiple-bag continuous ambulatory
Automated
Intermittent
Continuous-cycle
Complications of Peritoneal Dialysis*
Who would Not be a good candidate?
Peritonitis Pain Tunnel infections Poor dialysate flow Fibrin clot formation Dialysate leakage Other complications
(People at risk for infection or scar tissue in abd from multiple surgeries- not be good candidates)
? dialysis exchange for control of fluids, electrolytes, nitrogenous wastes, blood pressure, and acid–base balance.
Peritoneal
Nursing Care during In-Hospital PD
Before tx -
Continually monitor-
Before treatment: Evaluate baseline vital signs, weight, laboratory tests
Continually monitor patient for respiratory distress, pain, discomfort, fluid overload
Monitor prescribed dwell time, initiate outflow
Observe outflow amount and pattern of fluid
- if outflow is bloody, drainage, ect report to doc
Compare hemodialysis to peritoneal dialysis
Why might you choose one over the other?
68-9
Hemodialysis- more effectively clears waste, short time needed for tx
- don’t use with diabetes or vascular disease or diabetes or bleeding disorders.
- Fistula/ shunt
- Used in dialysis center- if at home needs training , second trained person present
Perioneal- flexible schedule for exchanges, fewer dietary restrictions
Don’t use if GI disease, ascities, obese, abdominal surgery recently
-intra-abdominal catheter
-easier for in home , less complex, one person
-continuous therapy and fewer side effects
You exchange fluid during the night.
Automated – a machine performs the exchanges overnight whilst you sleep.
Automated Peritoneal Dialysis
is done to remove wastes, chemicals, and extra fluid from your body.
a liquid called dialysate is put into your abdomen through a catheter (thin tube). The dialysate pulls wastes, chemicals, and extra fluid from your blood through the peritoneum.
Continuous ambulatory peritoneal dialysis (CAPD)
Hemofiltration
For patients too unstable for fluid shifts
12-24 hours each day
Uses ultrafiltration to remove wastes
Only in icu
Continuous kidney replacement
Manifestations of CKD
Progressive, irreversible disorder;
kidney function does not recover*
Longer than 3 months
End-stage kidney disease (ESKD)
Azotemia (build up of nitrogen)*-kidney doesn’t filter it out
Uremia (azotemia with symptoms)*
Uremic syndrome* (progression of uremia)
ESKD is fatal without renal replacement therapy
ESKD occurs when kidney function and waste elimination are too poor to sustain life
Uremia manifestations
Build up of nitrogen
Metallic taste Anorexia Nausea/vomiting Uremic frost on skin Itching Fatigue Hiccups Edema dyspnea
Cognitive changes
System changes with ckd
Kidney changes?
Metabolic changes?
Electrolyte changes?
Cardiac changes ?
Hematologic changes?
GI changes?
Cognitive changes?
Kidney changes
Neprhons become larger and work harder
Metabolic changes: hyponatremia, late stage hypernatremia, hyperkalemia, acidosis
Electrolyte changes*
(Keep eye on potassium)
Cardiac changes Hypertension Hyperlipidemia Heart failure Pericarditis
Hematologic/immunity changes
anemia
GI changes
Flora changes
Cognitive and functional changes* (confusion or comatose due to build up of uremia)
Stages of ckd
Stage 1 - at risk but not there yet
Table 68-6
CKD numbers increasing
Older adults
About 25% of patients receiving treatment for ESKD die when ??
in first year of dialysis
Health promotion and maintenance
Control diseases that lead to CKD
- Dm
- htn
Dietary adjustments Weight maintenance Smoking cessation Exercise Limitation of alcohol
How to prevent or delay CKD?
Don’t take nephrotoxic drugs such as aspirin/NSAIDs, antibiotics, statins, contrasts, ace inhibitors
Drink plenty water
BMI within normal range 18-24
Decrease sodium, cholesterol, and protein
Do not smoke
The nurse is teaching a patient with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which patient statements indicate a lack of understanding of the teaching? (Select all that apply.)
A: I need to decrease sodium, cholesterol, and protein in my diet
B: my weight should be maintained at a bmi of 30
C: smoking should be stopped as soon as I possibly can
D: I can continue to take an aspirin every 4-8 hours for my pain
E: I really only need to drink a couple of glasses of water each day
CKD assessment
Weight and height
Medical history, especially of kidney or urologic origin
Drug and medication use*
Dietary habits
GI and GU problems
Energy level
Physical assessment/signs and symptoms (chart 68-4)
Neurological and sensory changes
Fluid overload
Tachypnea and hyperpnea
Anemia, abnormal bleeding
Foul breath, mouth inflammation or ulceration
Osteodystrophy
Protein, sediment, or blood in urine
Skin discoloration
Psychosocial assessment for CKD
Anxiety, fear Coping styles Family relations- strained Social activity Work Body image Sexual activity
Diagnositic assessment of CKD
Laboratory assessment*
- Various blood and urine tests
- GFR estimated from BUN, serum -creatinine, age, gender, race, and body size
Imaging assessment
- x-ray findings
- Kidney or CT scan
Goals with CKD?
Nutrition goals?
Managing fluid volume
Preventing pulmonary edema
Increasing cardiac function
Enhancing nutrition
Preventing infection
Preventing injury
Minimizing fatigue
Reducing anxiety
Recognizing and managing depression
Nutrition: diet with fluid and potassium, sodium, phosphorus restrictions
Candidate criteria for kidney transplant selection?
Candidate selection criteria
- Free of problems that might raise -procedural risk
- Certain conditions preclude kidney transplant
Criteria for kidney donors
Donors
- Available kidneys matched based on tissue similarity between donor and recipient
- Organs from LRDs have highest rates of kidney graft survival
- Physical criteria must be met
Kidney transplantation pre-op care?
Operative procedures
Preoperative care
- Immunologic studies
- Dialysis 24 hours before surgery
Operative procedures
-Procedure varies depending on status of donor
Placement of transplanted kidney where?
Placement of a transplanted kidney in the pelvis-right iliac fossa.
Post op kidney transplant care?
Urologic management
Assessment of hourly urine output × 48 hours
Good fluid balance
Asses Complications
- Rejection
- Thrombosis
- Renal artery stenosis
- Other complications
Immunosuppressive drug therapy-immunosuppressed precautions
Contact sports restriction , hit in back
Kidney transplant complications may occur?
- Rejection
- Thrombosis
- Renal artery stenosis
- Other complications
A 70-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis.
Which precaution will the nurse follow to ensure the function of the AV graft?
A.Insert an IV and run saline at 10 mL/hr.
B.Keep the patient’s arm elevated on two pillows.
C.Monitor blood pressure and radial pulses in both arms.
D.Check for a bruit and thrill by auscultation and palpation over the site.
ANS: D
A positive bruit and thrill indicate good blood flow through the graft. A dialysis access should only be used for dialysis. IVs should not be started, nor should blood pressure be taken in the same arm where the access is located. Elevation of the arm will not ensure function of the graft.
The patient is to have hemodialysis this morning. Which drug should be held until after the dialysis treatment?
Calcium
Multivitamin
Atenolol (Tenormin)
GlyBURIDE (DiaBeta)
C
Vasoactive drugs such as beta blockers like atenolol can cause hypotension during dialysis and are usually held until after treatment.
After dialysis, the patient’s daughter asks why the dialysis nurses weighs her mother before and after the dialysis treatment. What is the most appropriate nursing response?
“It is part of the protocol for dialysis.”
“It ensures that she is getting adequate nutrition.”
“It estimates the amount of fluid and sodium your mother is retaining and how much is taken off during dialysis.”
“It is essential for calculating the fluid restriction your mother will receive on non-dialysis days.”
ANS: C
The best way to estimate fluid and sodium retention and removal is by weighing the patient.
Which teaching about post-dialysis care will the preceptor nurse provide to the student nurse who is helping to care for the patient?
Expect the patient’s blood pressure to be higher after dialysis.
The patient’s weight will most likely be increased after dialysis.
Expect the patient’s temperature to be higher after dialysis.
The patient’s clotting studies will need to be drawn after dialysis.
ANS: C
The patient’s temperature is elevated after dialysis because the dialysis machine warms the blood slightly. Weight and blood pressure should be decreased because excess fluid is removed during dialysis. Heparin is required during hemodialysis and increases clotting time. All invasive procedures should be avoided for 4 to 6 hours after dialysis.
As the patient is preparing to discharge, the nurse will teach her to restrict which elements in her diet? (Select all that apply.)
Potassium Phosphorus Calcium Protein Vitamins
ANS: A, B, D
Sodium is restricted because it causes retention of fluids. Potassium is restricted to prevent dangerous cardiac dysrhythmias. Vitamins must be supplemented, not restricted. There is an inverse relationship between phosphorus and calcium; when phosphorus is high, calcium is low and should not be restricted.
Mr. Rojas is a 49-year-old patient with End Stage Renal Disease. He has a history of hypertension and uncontrolled type 1 diabetes (since he was 12 years old). His last Hemoglobin A1c was 12.8%. He is currently receiving hemodialysis three times per week for three hours. He is in the hospital because he went into DKA a few days ago when he had a stomach virus. He is asking you about renal transplantation.
What are the criteria to be placed in the transplant list?
What options for transplantation does Mr. Rojas have?
What recommendations can you give Mr. Rojas on treatment compliance?
What other renal replacement therapies could Mr. Rojas be educated about?
What are their advantages and disadvantages?
?
Which clinical data requires immediate nursing intervention to prevent progression of acute kidney injury?
Heart rate of 120 beats/min
Blood pressure of 156/88
Urine specific gravity of 1.001 mm Hg
Intake of 2000 mL and output of 1500 mL in the past 24 hours
ANS: C
Decreased urine specific gravity indicates a loss of urine-concentrating ability and is the earliest sign of renal tubular damage and early kidney failure. Normal urine specific gravity ranges from 1.002 to 1.028. Assessing the patient’s perfusion status is also very important in the prevention and/or treatment of kidney disease.
A patient with end-stage kidney disease (ESKD) has this serum laboratory analysis K+ 5.9 mEq/L Na+ 152 mEq/L Creatinine 6.2 mg/dL BUN 60 mg/dL
What is the priority nursing intervention?
Assess heart rate and rhythm.
Implement seizure pregnancy.
Assess the patient’s respiratory status.
Evaluate the patient’s acid–base balance.
Answer: A
Patients with ESKD experience significant fluid and electrolyte imbalances that are managed with medications and dialysis. Hyperkalemia can be a life-threatening event. In patients with kidney disease, the myocardial response (heart rate and rhythm) to hyperkalemia should be assessed to effectively determine appropriate treatment. High sodium can increase the patient’s risk for seizures, excessive fluid balance will negatively effect breathing, and patients with ESKD experience acid–base imbalances from an inability to synthesize bicarbonate.
The nurse is caring for a patient who will soon receive a kidney transplant. When the patient says, “what will I do if this transplant doesn’t work?”, what is the appropriate nursing response?
“Kidney transplants are almost always successful.”
“It sounds like you are concerned about the outcome of the procedure.”
“If this transplant doesn’t work, I’m sure there will be another donor soon.”
“Try to focus on getting through the surgery first.”
ANS: B
The nurse should allow the patient to express his or her feelings; the patient’s question demonstrates concern—possibly anxiety or fear—and the nurse allows further exploration of those feelings by verbalizing the implied. Response A gives false reassurance; response C dismisses the patient’s feelings; response D does not address the patient’s feelings.
Types of dialysis?
- Vascular access via dialysis catheter
- A few times a week-short term) (hemodialysis) delivered over 3-6 hours
- used in hospitalized patients who are too unstable for changes in bp from ikrt. Runs over 12-24 hours* (These patients are very sick and would need to be in the hospital for this )
Vascular access via dialysis catheter
Intermittentw(a few times a week-short term) (hemodialysis) delivered over 3-6 hours
Continuous (hemofiltration): used in hospitalized patients who are too unstable for changes in bp from ikrt. Runs over 12-24 hours* (These patients are very sick and would need to be in the hospital for this )
