T3 Kidney Injury

Question 1

When kidney function is impaired it affects what organ systems

Answer 1

Fluid and electrolyte balance

Acid base balance

Urinary elimination

Excretion of waste

Hormone secretion

Question 2

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

Answer 2

Rapid reduction in kidney function resulting in failure to maintain fluid and electrolyte balance and acid–base balance

Dialysis

Question 3

Labs to watch for in AK

Main complications

Answer 3

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

Question 4

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 ?

Answer 4

CKD

return to full function

Question 5

Causes of AKI

Answer 5

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

Question 6

Prerenal causes of aki?

Answer 6

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

Question 7

Intrarenal causes of aki

Answer 7

glomerulonephritis, embolism in kidney, pyelonephritis, Nephrotoxic substances (table 68-5) ** meds hard on kidneys

68-4

Question 8

Postrenal causes of aki

Answer 8

bladder cancer, kidney stones, prostate cancer

Obstructs urine outflow

Question 9

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

Answer 9

B. MI

Question 10

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?

Answer 10

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*

Question 11

AKI hx to obtain ?

Answer 11

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

Question 12

What to asses in kidney injury

Answer 12

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*

Question 13

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

Answer 13

D: slow down the normal saline infusion

Fluid overload, stop fluid, reality to provider that you did and receive next orders

Question 14

Diagnostic assessment in AKI

Answer 14

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

Question 15

Interventions for AKI

Drug therapy?

Nutrition?

Answer 15

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)

Question 16

Kidney replacement therapy

Indications for it?

What does it do?

What is the cause?

Types?

Answer 16

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

Question 17

Intermittent Kidney Replacement

Answer 17

Outpatient vs inpatient

Dialysate helps remove unwanted waste products via diffusion

3-4 times weekly

Requires anticoagulation

Creates large fluid shifts*

Question 18

AV fistula graft

Check for what to assess patency?

Monitor for what?

No Bp on which arm ?

Answer 18

• 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)

Question 19

Siliconized rubber catheter placed into abdominal cavity for infusion of dialysate

Answer 19

Peritoneal Dialysis (PD)*

Question 20

Types of PD? (selection depends on patient’s ability and lifestyle)

Answer 20

Continuous ambulatory

Multiple-bag continuous ambulatory

Automated

Intermittent

Continuous-cycle

Question 21

Complications of Peritoneal Dialysis*

Who would Not be a good candidate?

Answer 21

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)

Question 22

? dialysis exchange for control of fluids, electrolytes, nitrogenous wastes, blood pressure, and acid–base balance.

Answer 22

Peritoneal

Question 23

Nursing Care during In-Hospital PD

Before tx -

Continually monitor-

Answer 23

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

Question 24

Compare hemodialysis to peritoneal dialysis

Why might you choose one over the other?

Answer 24

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

Question 25

You exchange fluid during the night.

Automated – a machine performs the exchanges overnight whilst you sleep.

Answer 25

Automated Peritoneal Dialysis

Question 26

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.

Answer 26

Continuous ambulatory peritoneal dialysis (CAPD)

Question 27

Hemofiltration

For patients too unstable for fluid shifts

12-24 hours each day

Uses ultrafiltration to remove wastes

Only in icu

Answer 27

Continuous kidney replacement

Question 28

Manifestations of CKD

Answer 28

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

Question 29

Uremia manifestations

Build up of nitrogen

Answer 29

Metallic taste
Anorexia
Nausea/vomiting
Uremic frost on skin
Itching
Fatigue
Hiccups
Edema
dyspnea

Cognitive changes

Question 30

System changes with ckd

Kidney changes?

Metabolic changes?

Electrolyte changes?

Cardiac changes ?

Hematologic changes?

GI changes?

Cognitive changes?

Answer 30

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)

Question 31

Stages of ckd

Stage 1 - at risk but not there yet

Answer 31

Table 68-6

Question 32

CKD numbers increasing
Older adults
About 25% of patients receiving treatment for ESKD die when ??

Answer 32

in first year of dialysis

Question 33

Health promotion and maintenance

Answer 33

Control diseases that lead to CKD

• Dm
• htn

Dietary adjustments
Weight maintenance
Smoking cessation
Exercise
Limitation of alcohol

Question 34

How to prevent or delay CKD?

Answer 34

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

Question 35

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.)

Answer 35

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

Question 36

CKD assessment

Answer 36

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

Question 37

Psychosocial assessment for CKD

Answer 37

Anxiety, fear
Coping styles
Family relations- strained 
Social activity
Work
Body image
Sexual activity

Question 38

Diagnositic assessment of CKD

Answer 38

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

Question 39

Goals with CKD?

Nutrition goals?

Answer 39

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

Question 40

Candidate criteria for kidney transplant selection?

Answer 40

Candidate selection criteria

• Free of problems that might raise -procedural risk
• Certain conditions preclude kidney transplant

Question 41

Criteria for kidney donors

Answer 41

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

Question 42

Kidney transplantation pre-op care?

Operative procedures

Answer 42

Preoperative care

• Immunologic studies
• Dialysis 24 hours before surgery

Operative procedures
-Procedure varies depending on status of donor

Question 43

Placement of transplanted kidney where?

Answer 43

Placement of a transplanted kidney in the pelvis-right iliac fossa.

Question 44

Post op kidney transplant care?

Answer 44

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

Question 45

Kidney transplant complications may occur?

Answer 45

• Rejection
• Thrombosis
• Renal artery stenosis
• Other complications

Question 46

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.

Answer 46

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.

Question 47

The patient is to have hemodialysis this morning. Which drug should be held until after the dialysis treatment?

Calcium
Multivitamin
Atenolol (Tenormin)
GlyBURIDE (DiaBeta)

Answer 47

C

Vasoactive drugs such as beta blockers like atenolol can cause hypotension during dialysis and are usually held until after treatment.

Question 48

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.”

Answer 48

ANS: C

The best way to estimate fluid and sodium retention and removal is by weighing the patient.

Question 49

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.

Answer 49

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.

Question 50

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

Answer 50

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.

Question 51

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?

Answer 51

?

Question 52

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

Answer 52

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.

Question 53

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 53

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.

Question 54

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.”

Answer 54

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.

Question 55

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 )

Answer 55

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 )