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Critical Care Nursing > Topic 5 Chapter 16 > Flashcards

Topic 5 Chapter 16 Flashcards

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1
Q

Kidneys
• Location
• Structure

A 
- Location
• Retroperitoneal area
- Structure 
• Cortex
• Medulla 
• Nephron
- Receives 20% to 25% of cardiac output
- Performs numerous functions
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2
Q

Fluids and electrolytes; waste
• Glomerular filtration rate (GFR)
• Hormonal control

A 
- Glomerular filtration rate (GFR)
• Result of pressure gradient
• 80 to 125 mL/min
• Reabsorption
• Secretion
- Hormonal control 
• Aldosterone
• Antidiuretichormone
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3
Q

Acid Base Balance

A
  • Reabsorption of filtered bicarbonate
  • Production of new bicarbonate
  • Excretion of small amounts of hydrogen ions
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4
Q

Kidney blood pressure regulation

A
  • Juxtaglomerular apparatus

* Renin-angiotensin-aldosterone

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5
Q 
The term used to describe accumulation of nitrogenous wastes is:
A. Anuria
B. Azotemia
C. Oliguria
D. Uremic syndrome
A

B. Azotemia

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6
Q

Acute kidney injury

A
  • Sudden deterioration of renal function
  • Oliguria: low urine output
  • Azotemia: accumulation of nitrogenous wastes
  • Acid-base disturbances
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7
Q

AKI Causes

A
  • Prerenal
  • Renal: intrinsic; parenchymal
  • Postrenal
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8
Q

Prerenal Etiology

A 
- Diminished blood flow; hypoperfusion of the kidney
• Volume depletion
• Vasodilation
• Decreased cardiac output
- Can progress to intrarenal damage
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9
Q

Intrarenal Etiology

A

• Kidney tissue affected directly
• Glomerular, vascular, and/or hematological
problem

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10
Q

Intrarenal Etiology

-Acute tubular necrosis (ATN)

A 
• Ischemia
• Nephro toxic agents 
  - Antibiotics
  - Nonsteroidal antiinflammatory drugs (NSAIDs) 
• Contrast-induced
• Rhabdomyolysis
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11
Q

Postrenal Etiology

A
  • Obstruction of flow
  • Increased intratubular pressure leads to decreased GFR
  • Reverses when obstruction is removed
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12
Q

Pathophysiology Summary
• Prerenal:
• Renal:
• Postrenal:

A
  • Prerenal: decreased blood supply
  • Renal: failure of nephrons
  • Postrenal: obstruction of outflow
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13
Q 
A treatment for postrenal etiology of AKI is:
A. Diuretic administration
B. Fluid administration
C. Nephrectomy
D. Ureteral stent placement
A

D. Ureteral stent placement

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14
Q

Course of AKI

-Initiation Phase

A
  • Initiation phase
    • Time from event to signs of decreased renal perfusion
    • Several hours to 2 days
    • Potentially reversible
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15
Q

Course of AKI

- Maintenance phase (oliguric/anuric)

A 
- Maintenance phase (oliguric/anuric)
• BUN and creatinine increase daily
• Oliguria is common
• Urine output less than 400 mL/day
• Fluidoverload,electrolyte imbalances, and acidosis 
• Renal replacement therapy required
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16
Q

Course of AKI

-Recovery phase

A
  • Recovery phase
    • Return of tubular function
    • 4 to 6 months for BUN and creatinine to return to normal
    • Residual impairment of GFR
    • Early dialysis may prevent the traditional “diuretic” phase of AKI
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17
Q

Assessment Patient History

- Predisposing factors

A 
- Disease states
• Hypertension
• Diabetes
• Immunological disease
• Hereditary disorders
- Hypotensive episodes
- Exposure to nephrotoxic agents
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18
Q

Clinical Presentation of AKI

A
  • Vital signs may be altered
    • Blood pressure changes, depending on etiology
    • Hyperventilation to compensate for metabolic acidosis
    • Body temperature may be altered
  • Assess for volume depletion and volume overload
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19
Q

Physical findings of AKI

- The patient’s general appearance is assessed for:

A

• Signs of uremia (malaise, fatigue, disorientation, and
drowsiness)
• Color and texture of skin
• Bruising, petechiae, and edema
• Current and admission body weight and intake and output
• Dehydration/fluid overload

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20
Q

Laboratory tests for AKI

A

• Serum creatinine
• Serum BUN
- Affected by catabolism, bleeding, and dehydration
• BUN:creatinine ratio
- Normal 10:1 to 20:1
- More than 20:1, suspect nonrenal causes of Laboratory abnormalities
- Urine creatinine clearance
• Estimate of GFR
• 24-hour urine; specific collection protocol
• Normal 84 to 138 mL/min
• Can calculate an estimated value with serum lab values (Cockcroft and Gault formula)

21
Q

Laboratory Findings

A
  • Specific gravity
  • Urine osmolality
  • Urine sodium
  • Microscopic examination
  • BUN/Creatinine ratio
  • FENa (the factional excretion of sodium)
22
Q

Urine tests for AKI

A
  • Urine electrolytes
  • Urine specific gravity
  • Urine osmolality
23
Q

Diagnostic studies for AKI

- Noninvasive tests

A 
- Noninvasive tests
• X-ray of kidneys, ureter, and bladder (KUB) 
  - Size, shape, and position of kidneys
  - Calculi, cysts, and tumors
• Renal ultrasound 
  - Size of kidneys
  - Obstruction
• MRI
24
Q

Diagnostic Studies

- Invasive tests (5)

A
  • IV pyelogram
  • Computed tomography
    • Structures,accumulationoffluid
  • Renal angiography
    • Abnormalities in blood flow; infarction; masses
  • Renal scan
    • Renal uptake of isotopes
  • Renal biopsy
    • Histological changes
25
Q

Which intervention is most important in assessing fluid balance in the patient with AKI?
A. Daily weight
B. Intake and output
C. Serumcreatinine D. Estimated GFR

A

A. Daily weight

26
Q

Nursing Diagnosis

- Assessment of overload or deficit

A 
- Excess fluid volume
  • Daily weight
    - 1 kg approximately 1000 mL fluid
    - 1 pound approximately 500 mL fluid
  • Intake and output (I&O)
27
Q

Nursing Diagnosis

A

• Imbalance fluid volume
• Electrolyte imbalance
• Risk for infection
- Strict aseptic care with IV lines
- Not all patients need urinary catheters; avoid use if not required
- Prevent progression of AKI with antibiotics
• Monitor peak and trough drug levels

28
Q

Nursing Diagnosis

- Imbalanced nutrition

A 
- Imbalanced nutrition 
• Small feedings
• Oral hygiene
• Intake in collaboration with dietitian
• Avoid fluid overload and electrolyte imbalance
- Anxiety
- Deficient knowledge
29
Q

Fluid and Electrolyte Imbalances

A 
- Hyperkalemia
  • Low excretion
- Hyponatremia
  • Fluid retention
- Hypocalcemia
  • Low excretion of phosphorus
  • Decreased level of vitamin D
- Hyperphosphatemia 
  • Low excretion
- Hypermagnesemia
  •Low excretion
30
Q

Medical Management-Prerenal

A
  • Early recognition
  • Fluid or volume replacement
  • Caution in patients with underlying cardiac disease
    • May require inotropes, antidysrhythmic agents, preload/afterload reducers, intraaortic balloon pump
    • May require hemodynamic monitoring to guide treatment
31
Q

Medical Management for Postrenal

A
  • Alleviate obstruction

* May need stent

32
Q

Medical Management for ATN

A
  • Medications
  • Dietary control
    • Protein and electrolyte restrictions
  • Management of fluid and electrolyte imbalances
  • Dialysis or CRRT
33
Q

Diuretic Therapy

A
  • Controversial
    • Convert oliguria to nonoliguric state
    • Hypovolemia corrected first • Loop (furosemide)
    • Osmotic (mannitol)
34
Q

Diuretic Therapy

A 
- Controversial
  • Convert oliguria to nonoliguric state
- Hypovolemia corrected first 
- Loop (furosemide)
- Osmotic (mannitol)
35
Q

Drug Therapy

A

1) Dopamine
• May increase renal blood flow
• Efficacy questioned in current research
2) Acetylcysteine, fenoldopam, theophylline
• Prevent contrast-induced AKI
3) Epoetin alfa
• Treat anemia
- Must adjust dosages and timing of medication if patient is on dialysis

36
Q

Dietary Management

A
  • Higher-than-normal basal requirement
  • Provide adequate energy, protein, and micronutrients
  • 25 to 35 kcal/kg of ideal body weight per day
  • Restricted
    • Protein
    • Sodium
    • Potassium
    • Fluid intake (output + 600-1000 mL)
37
Q

Hyperkalemia

A
  • Due to decreased GFR
  • Reduced content
    • Kayexalate
    • Mineralocorticoids
    • Diuretics
  • Shift intracellularly
    • Glucose and insulin
    • Alkali (sodium bicarbonate)
  • Antagonize cellular membrane effect
    • Calcium gluconate
38
Q

Hyponatremia

A
  • R/t fluid overload
  • Salt wasting can occur as nephrons damaged
  • Treated with fluid restriction
39
Q

Acid Base Imbalance

- Metabolic acidosis

A

• Treatment based on severity of imbalance
• May need IV bicarbonate
• Monitor ionized calcium as hypocalcemia can occur
as pH is corrected

40
Q

Renal Replacement Therapy

A
  • Lifesaving treatment
  • Classification
    • Hemodialysis
    • Continuous renal replacement therapy (CRRT)
    • Peritoneal dialysis
41
Q

Dialysis

- Two physical principles

A
  • Diffusion

* Ultrafiltration

42
Q

Dialysis Indications

A
  • Fluid overload
  • Electrolyte imbalances
  • Acid-base disturbances
43
Q

Vascular Access

A
  • Percutaneous catheters
  • Arteriovenous fistulas
  • Grafts
  • External shunts
44
Q

Hemodialysis

A
  • Usually done at the bedside in the ICU
  • Pre- and postdialysis labs and weight
  • Monitor for complications
    • Volume depletion
    • Dysrhythmias
    • Hypoxemia
    • Disequilibrium syndrome
    • Vascular access infections
45
Q

Continuous Renal Replacement Therapy (CRRT)

A
  • Used with patients too unstable for hemodialysis
  • Advantages
    • More gradual solute removal
    • Flexible fluid administration
    • Minimal heparin
    • Can be done by staff nurses at the bedside
  • Disadvantages
    • Bed rest
    • One-to-one nursing care
46
Q

CRRT Types

A
  • CAVH—continuous arteriovenous hemofiltration
  • CVVH—continuous venovenous hemofiltration
  • CAVHD—continuous arteriovenous hemodialysis
  • CVVHD—continuous venovenous hemodialysis
47
Q

Peritoneal Dialysis

A
  • Removal of solutes and fluids using the peritoneal membrane as a filter
  • Rarely used in the critical care setting because it is less efficient
  • High risk of peritonitis
48
Q

Geriatric Considerations

A
  • Normal decline owing to aging
  • Comorbidities
  • Diabetes
  • Hypertension
  • Prescribed medications

Critical Care Nursing (15 decks)

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