Chapter 47 Nursing Management Acute Kidney Injury And Chronic Kidney Disease

Front 1

BUN Normal Range

Back 1

6-20 mL/dL. Urea is the major nitrogenous end product of protein metabolism.

Front 2

What should the nurse be aware of when interpreting a BUN level?

Back 2

Nonrenal factors can cause an increase in BUN such as rapid cell destruction, fever, GI bleed, trauma, athletic activity, muscle breakdown and corticosteroid therapy

Front 3

Creatinine normal range

Back 3

0.6-1.3 mg/dL

Front 4

What is a more reliable determinant of renal function BUN or creatinine?

Back 4

Creatinine

Front 5

What is creatinine?

Back 5

End product of protein/muscle metabolism

Front 6

Normal BUN/creatinine ratio

Back 6

12:1 or 20:1

Front 7

What is uric acid?

Back 7

Waste product normally present in blood as a result of breakdown of pruine

Front 8

What is uric acid used for in screening a pt?

Back 8

Screening test primiarily used for disorders of purine metabolism but can also indicate kidney disease.

Front 9

What influences uric acid values?

Back 9

Renal function, rate of purine metabolism, and dietary intake of food rich in purines

Front 10

What is purine?

Back 10

Organic compound found in many proteins

Front 11

What is creatinine clearance?

Back 11

Creatinine by kidney approximates the GFR

Front 12

Equation to determine creatinine clearance

Back 12

Urine creatinine (mg/dL) x urine volume (mL/min)/serum creatinine (mg/dL)

Front 13

How to collect creatinine clearance results? What kind of collection is it?

Back 13

24 hours urine. Discard first urination when test starts. Save urine from all subsequent urinations for 24 hours.

Front 14

Acute Kidney Injury

Back 14

Rapid loss of kidney function from renal cell damage

Front 15

What can AKI lead to?

Back 15

Hypoperfusion, cell death and decompensation of renal function.

Front 16

Azotemia

Back 16

Abnormally high levels of nitrogen containing compounds (urea, creatinine, body waste compounds and other nitrogen rich compounds) in the blood.

Front 17

Etiology of AKI categories

Back 17

Pre-renal, intra-renal, post-renal

Front 18

Pre-renal etiology of AKI

Back 18

External the kidney, caused by intravascular volume depletion, dehydration, decreased cardiac output, decreased peripheral vascular resistance, and infection

Front 19

What is the most common category of etiology of AKI?

Back 19

Pre-renal

Front 20

Intra-renal etiology AKI

Back 20

Within the parenchyma of the kidney, caused by tubular necrosis, prolonged prerenal ischemia, intrarenal infection or obstruction, and nephrotoxicity.

Front 21

Post-renal etiology of AKI

Back 21

Between the kidney and urethra meatus such as bladder neck obstruction, cancer and calculi

Front 22

What are primary causes of s/s of AKI?

Back 22

Retention of nitrogenous wastes, retention of fluids and the inability of kidneys to regulate electrolytes

Front 23

Oliguric Phase of AKI S/S

Back 23

Sudden decrease in urine output (<400 mL/day), excess fluid volume, metabolic acidosis, neuro changes, labs, nursing interventions.

Front 24

What are some s/s of excess fluid volume in the oliguric phase?

Back 24

Htn, edematous, SOB, heart dysrhythmias, HF and pulmonary edema.

Front 25

What are some s/s of metabolic acidosis in the oliguric phase?

Back 25

Kussmauls respirations

Front 26

What are some s/s of neuro changes in the oliguric phase?

Back 26

Drowsiness may progress to coma

Front 27

What are some lab values that are found with oliguric phase?

Back 27

increased creatinine/BUN, normal or decreased Na. Decreased specific gravity and decreased GFR

Front 28

What are nursing interventions for pts in the oliguric phase?

Back 28

Restrict fluids, admin meds such as furosemide (Lasix) to increase renal blood flow and diuresis

Front 29

Diuretic phase in AKI

Back 29

Urine output rises slowly, followed by diuresis (4-5 L/day), dehydration, hypovolemia, hypotension, tachycardia, LOC improves, labs, and nursing interventions

Front 30

What are some labs in the diuretic phase?

Back 30

Gradual decline in BUN/creatinine, hypokalemia, hyponatremia, hypovolemia, GFR improves.

Front 31

Nursing Interventions in diuretic phase

Back 31

Adminster fluids which may contain electrolytes

Front 32

Recovery phase (convalescent) in AKI

Back 32

Slow process complete recovery may take 1-2 years, urine volume returns to normal, memory improves, strength improves, GFR increases allows creatinine/BUN to plateau and decrease

Front 33

What is a sign that recovery phase is occurring?

Back 33

GFR increases

Front 34

Important interventions for AKI

Back 34

Monitor VS, monitor weight same time same scale same clothes, I/O, examine urine for color, specific gravity, glucose, protein, blood or sediment, assess general appearance, monitor ECG and LOC

Front 35

Causes of AKI in older adults

Back 35

Dehydration, antibiotics, prolonged aminoglycoside therapy, prostatic hyperplasia, surgery, infection and radiocontrast agents.

Front 36

Chornic kidney disease

Back 36

Progressive, irreversible los sof kidney function, presence of kidney damage or decreased GFR less than 60 for longer then 3 months

Front 37

What is the GFR in CKD?

Back 37

Less than 60 for 3 months or more

Front 38

What is the GFR is end-stage renal failure

Back 38

15 mL/minute

Front 39

What is the leading cause of CKD and the second leading cause?

Back 39

Diabetes (50%) and hypertension (25%)

Front 40

Chronic Renal Failure S/S

Back 40

Headache, decreased ability to concentrate urine, polyuria->oliguria, increased BUN/creatinine, edema, GFR <90 to 30 mL/minute, mild anemia, increased BP, and weakness/fatigue

Front 41

Chronic Renal Failure End-Stage S/S

Back 41

Neurological weakness, fatigue, confusion, htn, pitting edema, periorbital edema, increased CVP, pericarditis, SOB, depressed cough, thick sputum, ammonia odor to breath, metallic taste, mouth/gum ulcerations, anorexia, N/V, withdrawn, behavior changes, anemia, dry flaky skin, pruritus, ecchymosis, purpura, cramps, renal osteodystrophy, and bone pain.

Front 42

In hemodialysis pt what is something to keep in mind when taking BP or blood samples?

Back 42

Do not take BP or blood from arm that has access site. evaluate for patency and S/S of infection

Front 43

Uremia

Back 43

Syndrome that incorporates all s/S seen in the various systems throughout the body in CKD

Front 44

Chronic kidney disease creatinine, BUN and GFR levels

Back 44

Decreased GFR, increase BUN/creatinine

Front 45

S/S of increased BUN

Back 45

N/V, lethargy, fatigue, impaired thought process and headaches

Front 46

Electrolyte imbalances in Chronic Kidney Disease in potassium, sodium and alkalosis or acidosis?

Back 46

Hyperkalemia, hyponatremia, and metabolic acidosis

Front 47

When do fatal dysrhythmias occur with potassium levels?

Back 47

Potassium above 7-8 mEq/L

Front 48

What is hyperkalemia due to in CKD?

Back 48

Decreased excretion from the kidneys

Front 49

Why does metabolic acidosis occur in CKD?

Back 49

Kidneys impaired ability to excrete the acid load (primiarily ammonia)

Front 50

Why does anemia occur in CKD?

Back 50

Decreased production of hormone erythropoietin by the kidneys.

Front 51

What does erythropoietin do?

Back 51

Stimulates bone marrow to produce RBCs

Front 52

Why does bleeding tendencies occur in CKD?

Back 52

Due to defect in platelets function

Front 53

What is the most common cause of death in CKD?

Back 53

Cardiac related disease, MI, ischemic heart disease, PAD, HF, cardiomyopathy, and stroke

Front 54

Why do neuro changes occur in pts w/ CKD?

Back 54

Increased nitrogen waste products, electrolyte imbalances, metabolic acidosis, and demyelination of nerve fibers.

Front 55

What is usually the first indication of kidney damage?

Back 55

Persistent proteinuria

Front 56

What do they do to screen for CKD?

Back 56

Dipstick evaluation of protein in the urine or evaluation for microalbumineria

Front 57

What can a urinalysis detect?

Back 57

RBCs, WBCs, protein, casts, glucose.

Front 58

What can an ultrasound detect in CKD patients?

Back 58

Usually done to detect any obstructions and to determine the size of the kidneys

Front 59

What is the preferred method of measurement to determine kidney function?

Back 59

GFR

Front 60

In increased K+ the ____ waves are peaked and the widened ___ complexes

Back 60

T waves, QRS complexes

Front 61

What medication should not be given to a pt w/ a paralytic ileus and why?

Back 61

Kayexalate, bowel necrosis can occur.

Front 62

What's the indication that a pt has paralytic ileus?

Back 62

Absent bowel sounds.

Front 63

What are some therapies for pt w/ high K?

Back 63

Regular insulin IV, sodium bicarbonate, calcium gluconate IV, dialysis, sodium polystyrene sulfonate (Kayexalate) and dietary restriction

Front 64

What does sodium bicarbonate do to decrease potassium?

Back 64

Can correct acidosis and cause a shift of potassium into cells

Front 65

When calcium gluconate IV generally used in pts w/ hyperkalemia?

Back 65

Advanced cardiac toxicity

Front 66

What kind of dialysis is the most effective to remove potassium?

Back 66

Hemodialysis, works most effectively in a short period of time.

Front 67

What is dietary restriction for potassium w/ hyperkalemia?

Back 67

40 mEq/day

Front 68

Most commonly used antihypertensive drugs with CKD

Back 68

Diuretics, CCB, ACE inhibitors, and ARB agents.

Front 69

Who are ACE inhibitors and ARBs in primiarily w/ pts w/ CKD?

Back 69

Diabetics and non-diabetic proteinuria.

Front 70

What medications are used for anemia in CKD?

Back 70

epoetin alfa (Epogen, Procrit)

Front 71

How long does it take for medications for anemia to increase and be effective?

Back 71

2-3 weeks

Front 72

What is nutritional therapy for CKD?

Back 72

Protein restriction, water restriction, Na/K restriction, phosphate restriction.

Front 73

What drugs should be avoided w/ pts w/ CKD?

Back 73

NSAIDs, High phosphate enemas, aluminum/magnesium based laxatives and antacids

Front 74

Why should NSAIDs be avoided?

Back 74

Nephrotoxic, most concern is ibuprofen

Front 75

Why should high phosphate enemas be avoided in pts w/ CKD?

Back 75

Elevated BUN/creatinine because phosphate cannot be excreted by pts w/ renal failure

Front 76

Why should aluminum and magnesium based laxatives

Back 76

Magnesium is excreted by kidneys.

Front 77

What are some important teaching points in pts w/ CKD?

Back 77

Daily BP, S/S fluid overload, hyperkalemia and electrolyte imbalances

Front 78

What are some ways a pt can reduce thirst w/ CKD?

Back 78

Suck on ice cubes, hard candy and lemon

Front 79

What are some important factors the pt should report to healthcare provider w/ CKD?

Back 79

Wt gain greater than 4 lb (2 kg), increasing BP, SOB,edema, increasing fatigue/weakness, and confusion/lethargy

Front 80

How can you estimate a pts GFR?

Back 80

GFR=140-(your age)

Front 81

How much will GFR decrease due to normal aging process?

Back 81

0.5-1 mL/minute

Front 82

Dialysis

Back 82

Movement of fluid and molecules across a semipermeable membrane from one compartment to another. Used to correct fluid and electrolyte imbalances and to remove waste products in kidney failure. Also used for drug overdoses.

Front 83

Two methods of dialysis

Back 83

Peritoneal and hemodialysis

Front 84

Peritoneal dialysis

Back 84

Peritoneal membrane acts as the semipermeable membrane

Front 85

Hemodialysis

Back 85

Artificial membrane is used as the semipermeable membrane and is in contact w/ the pts blood

Front 86

Diffusion

Back 86

Movement of solutes from an area of higher concentration to an area of lower concentration.

Front 87

What are too large to pass in dialysis?

Back 87

RBCs. WBCs, plasma proteins.

Front 88

What is moved in dialysis?

Back 88

Creatinine, urea, uric acids, electrolytes (potassium, phosphate)

Front 89

Osmosis

Back 89

Movement of solvent (fluid) from an area of lesser concentration to an area of greater concentration of solutes. Pulls excess fluid from blood.

Front 90

What are some advantages of peritoneal dialysis?

Back 90

Home dialysis possible, fewer dietary restrictions, less cardiovascular stress, preferred w/ diabetics.

Front 91

Disadvantages of peritoneal dialysis

Back 91

Bacterial/chemical peritonitis, protein loss, exit site/tunnel infections, best done w/ partner, catheter can migrate.

Front 92

Hemodialysis advantages

Back 92

Rapid fluid removal, rapid removal of urea and creatinine, effective potassium removal, less protein loss, home dialysis possible.

Front 93

Hemodialysis disadvantages

Back 93

Vascular access problems, dietary and fluid restrictions, heparin may be needed, hypotension during, added blood loss, specialist necessary, self image problems w/ permanent access.

Front 94

Where is peritoneal dialysis access?

Back 94

Anterior abdominal wall.

Front 95

Three phases of peritoneal dialysis

Back 95

Inflow (fill), dwell phase (equilibrium), and drain

Front 96

Inflow (Fill) phase peritoneal dialysis

Back 96

Prescribed amount of solution usually 2 L infused over time

Front 97

Dwell phase peritoneal dialysis

Back 97

Diffusion/osmosis occur between patient's blood and peritoneal cavity.

Front 98

What doesn't an extended dwell time increase risk of?

Back 98

Hyperglycemia in pt w/ diabetes

Front 99

Drain stage peritoneal dialysis

Back 99

Fluid removal stage

Front 100

Two types of peritoneal dialysis

Back 100

Automated peritoneal dialysis and continuous ambulatory peritoneal dialysis

Front 101

Automated Peritoneal Dialysis

Back 101

Most popular; allows pts to accomplish dialysis while they sleep, automated cycles control the fill, dwell and drain phases. Machine cycles four or more exchanges per night 1-2 hours per exchange.

Front 102

Continuous Ambulatory Peritoneal Dialysis

Back 102

More laborious, and is done while the pt is awake during the day.

Front 103

Most common complications in peritoneal dialysis

Back 103

Infection of the peritoneal catheter, exit site, peritonitis, and pain. Hematuria, lower back pain, protein loss, bleeding (uncommon), atelectasis, pneumonia, and bronchitis

Front 104

What is a sign of peritonitis in pts w/ peritoneal dialysis?

Back 104

Cloudy appearance of peritoneal effluent.

Front 105

Types of vascular access in hemodialysis

Back 105

Arteriovenous fistulras (AVFs) and arteriovenous grafts (AVGs) and temporary/semipermanent catheters

Front 106

Arteriovenous fistula (AVF)

Back 106

Most commonly created in forearm w/ an anastomosis between an artery and vein. Has the best patency rates leasat number of complications. Less likely to clot, less risk of infection.

Front 107

Arteriovenous grafts (AVG)

Back 107

Made of synthetic materials and form a bridge between artery and vein. more likely to become infected and form thrombus

Front 108

In hemodialysis what do you palpate what do you auscultate?

Back 108

Palpate a thrill and auscultate a bruit

Front 109

Risk for arteriovenous access for hemodialysis

Back 109

Development of distal ischemia and pain because too much of arterial blood is being shunted from the distal extremity and aneurysms can develop

Front 110

What is added to blood as it flows into dialyzer in hemodialysis to prevent blood clots?

Back 110

Heparin

Front 111

What is the red catheter lumen used for in hemodialysis?

Back 111

Used to pull blood from the pt to the dialyzer

Front 112

What is the blue catheter lumen used for in hemodialysis?

Back 112

Returns blood from dialyzer to the pt

Front 113

How is heparin infused in hemodialysis?

Back 113

Continuous pump or bolus

Front 114

Before beginning hemodialysis what do you need to do?

Back 114

Find the difference between the postdialysis weight and present predialysis weight which determines the unltrafiltration or amount of weight to be removed. Take VS. Pt may develop an elevated temp following dialysis because of warming of the blood

Front 115

How often do pts on hemodialysis get treatment?

Back 115

Q3-4 hours 3 days a week

Front 116

Complications of hemodialysis

Back 116

Hypotension, muscle cramps, blood loss, and hepatitis B and hepatitis C

Front 117

What is the reason hypotension happens in pts on hemodialysis?

Back 117

Primarily results from rapid removal vascular volume, decreased C/O, and decreased systemic vascular resistance. Tx is usually done w/ normal saline.

Front 118

Contraindications for kidney transplant

Back 118

Disseminated malignancies, refractory/untreated cardiac disease, chronic respiratory failure, extensive vascular disease, chronic infection, and unresolved psychosocial disorders.

Front 119

What are some diseases that are not contraindicated to transplants?

Back 119

HIV, hepatitis B and C.

Front 120

What are some goals of postop kidney transplant surgery?

Back 120

Prevention/tx of rejection, infection, and complications of surgery, and complications of surgery and purpose/side effects of immunosuppression.

Front 121

What is the first priority of caring for a pt post op of kidney transplant

Back 121

Maintenance of fluid and electrolyte balance

Front 122

What are other nursing assessments for pt post op of kidney transplant?

Back 122

Monitor renal function for impairment, hct for bleeding and I/Os

Front 123

What is a major problem post op kidney transplant?

Back 123

Rejection.

Front 124

What is used to prevent rejection of kidney in transplant?

Back 124

Immunosuppressive therapy.

Front 125

What is a significant cause of morbidity after kidney transplant?

Back 125

Infection.

Front 126

What are ways to prevent the complication of infection after kidney transplant?

Back 126

Prophylactic antifungals.

Front 127

What is the leading cause of death postop kidney transplant?

Back 127

Cardiovascular disease.

Front 128

What can contribute to cardiovascular disease after kidney transplant?

Back 128

Htn, hyperlipidemia, diabetes mellitus, smoking, rejection, infections, and increased homocysteine.

Front 129

What is the cause of malignancies in kidney transplant primarily?

Back 129

immunosuppresive therapy.

Front 130

What are corticosteroid related complications in kidney transplant pts?

Back 130

Aseptic necrosis of hips, knees, and other joints.