Acute Kidney Injury CAE PNCI Medical Surgical Study Review, Exams of Nursing

Download Acute Kidney Injury CAE PNCI Medical Surgical Study Review and more Exams Nursing in PDF only on Docsity! Acute Kidney Injury CAE PNCI Medical Surgical Study Review Preparation Questions • Describe the pathophysiological changes that occur with acute kidney injury. o As the flow of urine is obstructed, urine refluxes into the renal pelvis, impairing kidney function. o Bilateral ureteral obstruction leads to hydronephrosis (kidney dilation), an increase in hydrostatic pressure, and tubular blockage. This results in a progressive decline in kidney function. o If bilateral obstruction is relieved within 48 hours of onset, complete recovery is likely. o Prolonged obstruction can lead to tubular atrophy and irreversible kidney fibrosis. o Severe kidney ischemia causes a disruption in the basement membrane and patchy destruction of the tubular epithelium. • Differentiate between the causes, signs, symptoms and diagnostic findings in prerenal, intrarenal and postrenal acute kidney injury. o Prerenal Causes of AKI ▪ Hypovolemia (dehydration, hemorrhage, diarrhea, vomiting, excessive diuresis, hypoalbuminemia, and burns) ▪ Decreased cardiac output (cardiac dysrhythmias, cardiogenic shock, heart failure, and myocardial infarction) ▪ Decreased peripheral vascular resistance (anaphylaxis, neurologic injury, and septic shock) ▪ Decreased renal vascular blood flow (bilateral renal vein thrombosis and hepatorenal syndrome) ▪ Renal artery thrombosis o Intrarenal causes of AKI ▪ Nephrotoxic injury (aminoglycosides; vancomycin; amphotericin B; contrast media; hemolytic blood transfusion reactions; severe crushing injury; and chemical exposure to ethylene glycol, lead, arsenic, or carbon tetrachloride) ▪ Interstitial nephritis (antibiotics such as sulfonamides or rifampin, nonsteroidal anti-inflammatory drugs, ACE inhibitors, viral, fungal or bacterial infections such acute pyelonephritis, CMV, or candidiasis) ▪ Other causes (prolonged prerenal ischemia, acute glomerulonephritis, thrombotic disorders, toxemia of pregnancy, malignant hypertension, and systemic lupus erythematosus) o Post renal causes of AKI ▪ benign prostatic hyperplasia, ▪ bladder cancer, ▪ prostate cancer, ▪ calculi formation, ▪ neuromuscular disorders, ▪ spinal cord disease, ▪ strictures, and trauma to the back, pelvis, or perineum. o Signs and Symptoms: Oliguria, SOB, swelling in legs and ankles, chest pain and pressure, fatigue, nausea, dry mucous membrane, seizures, and coma • What fluid and electrolyte disturbances commonly occur with acute kidney injury? o decreased Na+, hyperkalemia, hypocalcemia, • What are the causes, signs and symptoms that correlate with each electrolyte disturbance? • Cause of hyperkalemia and manifestations: o Renal insufficiency, metabolic acidosis, o S&S: Muscle weakness, paresthesia’s, bradycardia, irritability, leg cramps, dysrhythmias, abdominal cramping or diarrhea ▪ Cause of Hyponatremia and manifestations: ▪ Water deprivation (dehydration), and hypovolemia or hypervolemia ▪ S&S: Abdominal cramping, headache, dry and sticky mucous membrane and confusion ▪ Hypocalcemia causes and manifestation ▪ Related to increases in serum phosphorus levels caused by reduced GFR S&S: Tetany, Numbness, tingling in fingers and toes and around mouth, positive Trousseau's sign & Chvostek's sign, irritability, bronchospasm • Describe the medical and nursing management of a patient with acute kidney injury. Include discussion of fluid administration, treatment of common electrolyte imbalances o Tell the patient to increase fluid intake • Describe MRSA and its implications for patients. o MRSA is a cause of staph infection that is difficult to treat because of resistance to some antibiotics o Most MRSA infections occur to people who are in hospital or nursing care facilities such as nursing homes or dialysis centers. These types of infections are called HA-MRSA o Patients who leave the hospital with MRSA can spread it to their communities. • Discuss how patients can be protected from hospital-acquired MRSA. o Hand hygiene before and after leaving a room o wearing gloves and gown when assessing or draining wound o Place infected patient in a private room or in a room with those of the same infection o administration of antibiotics prescribed by the doctor @ right time consistently so that the drug is at maximum effectiveness o patient education: ▪ educate patient about their illness and medications ▪ educate on not sharing of razors, towels, or toothbrushes w/ family ▪ proper disposal or PPE ▪ importance of hygiene ▪ proper nutrition ▪ stress management • Discuss the differences between peritoneal dialysis and hemodialysis. o Hemodialysis is the perfusion of blood and a physiologic solution on opposite sides of a semipermeable membrane. Blood is removed from the body o Peritoneal: the blood is not removed from the body- instead the peritoneal cavity is flooded with dialysate and the peritoneal membrane serves as the semipermeable membrane Patient History Past Medical History: • Hypertension and hyperlipidemia • MRSA nine years ago Allergies: • Penicillin Medications: • Enalapril 20 mg PO daily • Atorvastatin 10 mg PO daily • Baby aspirin 325 mg PO daily Code Status: • Full code Social/Family History: • Works as an electrical engineer at local engineering firm • Divorced with two adult children • Significant other is at the bedside • Smokes one pack of cigarettes per day • Denies drug use • Reports one alcoholic drink every evening Handoff Report Situation: • The patient is a 61-year-old individual who underwent an emergency open cholecystectomy for obstructive jaundice • Showed progressive improvement until last night, when the patient began having a low- grade fever, nausea, vomiting, absent bowel sounds and a urine output of only 250 mL over 12 hours • Patient reports no bowel movement in three days • Surgical wound is positive for MRSA, which is now being treated with vancomycin • The patient is in contact isolation • The patient’s significant other is at the bedside Background: • The patient presented to the ED one day ago with complaints of upper right abdominal pain and yellow skin • Patient reported feeling nauseated and described pain as a “terrible, aching, gnawing and sharp” pain that radiated to the right shoulder and scapula • The primary diagnosis was cholecystitis, and a cholecystectomy was performed one day ago • On the first postoperative day, the IV was converted to a saline lock and the patient was started on clear liquids Assessment: Vital Signs: • HR 110 • BP 90/60 • RR 28 • SpO2 has been 90% on room air • Temperature 37.9C General Appearance: • Weak-appearing, well-groomed male who appears the stated age Cardiovascular: • Sinus tachycardia • Peripheral pulses weak bilaterally Respiratory: • Breath sounds diminished throughout GI: • Bowel sounds absent • Abdomen firm and distended • Nauseated and vomited green and yellow emesis x 2 Temperature of 37.9C Other Assessment Findings: Cardiac rhythm is Sinus tachycardia Pulses weak bilaterally Breath sounds are diminished Bowel sounds are absent Abdomen is firm and distended Complaining of nausea and lower abdominal pain, rates pain 5 out of 10 Vomited green and yellow emesis twice Voided 15 mL of dark amber urine Dressing on incision is dry, with a small amount of serous drainage Awake, alert, and oriented to person, place and time Anxious related to the vomiting Pupils are equal, round and reactive to light and accommodation Significant other is at the bedside, quiet, but appears concerned What would be appropriate interventions for state 1? o O2 supplemental o ECG o Raise the head of the bed o 0.9 NS IV o Notify physician about unstable vitals and low urine output Lab results received in State 1: CBC: WBC 12, RBC 5.2, Hgb 12, Hct 36%, Platelets 92 Chemistry: Na 150, K 5.2, Cl 116, CO2 18, Glucose 96, BUN 50, Creatinine 2.6 Orders Received in State 1: NS 500 mL bolus followed by NS continuous infusion at 150 mL/hour Discontinue vancomycin STAT Discontinue HYDROmorphone and OxyCODONE Notify provider if complaints of pain Continue to hold Enalapril and Enoxaparin Urinary catheter to gravity drainage Hourly intake and output Nasogastric tube to low intermittent wall suction NPO Complete bedrest 12 lead EKG Oxygen per nasal cannula at 2 LPM; titrate to maintain SpO2 greater than 92% Electrolytes, BUN, creatinine, glucose, urinalysis, urine osmolality, urine sodium STAT and call results to healthcare provider. Questions to consider: What is the expected normal hourly urine output? When should the nurse notify the healthcare provider? o Normal expected hourly urine output is 30-60 mL/hr o Notify provider if less than 250mL/8hr What could be causing this patient’s urine output to decrease? o Sudden onset of AKI What should the nurse do when decreasing urinary output is suspected? o Assess for AKI, UTI, hypovolemic shock o Fluid replacement and fluid challenge o Bladder scan to check for retention What is the earliest sign of acute kidney injury? o Oliguria What conditions contributed to the development of acute kidney injury in this patient? o Use of vancomycin and hypovolemia What type of acute kidney injury (prerenal, intrarenal or postrenal) should the nurse suspect this patient has developed? Why? o Drug related toxicity: intrarenal Why should the nurse discontinue the vancomycin? o One of the adverse effects of this is nephrotoxicity What is the best method of confirming proper placement of a nasogastric tube? o X-RAY Why should the nurse hold the antihypertensive and anticoagulant? o Patient’s bp is already low o Also, Patient may need dialysis and these medications are contraindicated to perform dialysis Why is it important to initiate incentive spirometry? o To prevent lung collapse What is MRSA and why is it necessary for the patient to be in isolation? o MRSA is the cause of staph infection and easily spread from person to person What could be causing this patient’s hypoxia? o Hypovolemia and low bp What is the rationale for the fluid bolus? o Fluid replacement, o To correct hypotension o To prevent shock Why is it essential to monitor intake and output? o To monitor kidney function What is the rationale for the insertion of the nasogastric tube? o To fix metabolic acidosis by suctioning How would acute kidney injury affect the urine sodium and urine osmolality? o Due to electrolyte imbalance from poor kidney function o Kidney plays a major role in balancing electrolytes State 2 Condition Deteriorates Due to intrarenal failure and fluid volume excess, takes place three hours later. Vital Signs: HR in the 120s BP in the 90s to 100s/60s to 70s RR in the 30s SpO2 in the high 80s on oxygen at 2 LPM via nasal cannula Temperature is 37.9C Other Assessment Findings: Breath sounds reveal crackles Cardiac rhythm is sinus tachycardia Upon auscultation, a S3 sound is heard Peripheral pulses are bounding Urine output is 10 mL over the last three hours Temperature of 37.9C Other Assessment Findings: Weight is 100 kg Cardiac rhythm is Sinus tachycardia S1 and S2 sounds are easily auscultated Crackles are still present throughout the lung fields Bowel sounds are absent Urine output is 10 mL The patient is also asking questions about why hemodialysis is needed and placement of a catheter for it What would be appropriate interventions for state 3? o Notify physician about patient’s concern and questions of hemodialysis o Reinforce teaching on hemodialysis for AKI o Check for informed consent o Assess vital signs, weight, and lab values o Continuous monitoring of ECG o Prepare patient for hemodialysis procedure Questions to consider: What ECG changes should the nurse look for with hyperkalemia? o Elevated T waves When is emergency dialysis required? o Acute kidney injury with client present with fluid volume changes, electrolyte and pH imabalance and high serum nitrogenous waste What ECG change will occur if the potassium level falls too low and the patient becomes hypokalemic? o Prolonged PR interval o Widened QRS complex What is the purpose of weighing the patient before and after dialysis? o It will help in comparing patient’s preprocedural weight with the postprocedural weight; a way to estimate the amount of fluid removed How will the nurse know if the patient is improving? o By stable vital signs o Improved condition o Improved dyspnea and clear breath sounds State 4 Improvement After Dialysis Three hours later the patient has had the placement of the vascular access device to the right subclavian and underwent hemodialysis. Post Dialysis Report: Tolerated well One liter of fluid removed Vital signs following hemodialysis were HR 88, BP 112/68, RR 18 and SpO2 95% on 4 LPM per nasal cannula Weight is now 99 kg Patient returned to Medical-Surgical unit Vital Signs: HR in the 80s BP in the 100s to 110s/60s to 70s RR in the teens SpO2 in the mid-90s on oxygen at 4 LPM via nasal cannula Temperature of 37.2C Other Assessment Findings: Cardiac rhythm is Sinus Breath sounds are clear Bowel sounds are absent Urine output is 10 mL over the past four hours Patient is alert and oriented to person, place and time What would be appropriate interventions for state 4? o Monitor for post procedure complications ▪ Such as hypotension, disequilibrium syndrome, and infections o Implement standard precautions o Monitor vital signs o Provide education on how to care the fistula Lab results received in State 4: Chemistry: Na 143, K 4.5, Glucose 97, Calcium 8.5, Cl 103, CO2 23, BUN 38, Creatinine 3.1 Questions to consider: Why have the patient’s lungs cleared? o Due to fluid overload patient had fluid accumulation in lungs. Dialysis helped in getting rid of extra fluid volume thus reducing fluid in lungs and improving lung sounds. What complications can occur during and after dialysis? o Infection/clotting of the access site o Disequilibrium syndrome o Anemia o Infectious diseases o Hypotension o muscle cramps o pruritis o nausea and vomiting o headache o chest pain o fever and chills Why can’t the nurse use the dialysis catheter for routine IV fluids, medications and labs? o To prevent complications such as infections, to reduce the risk of altering medication effectiveness, to reduce the risk of altering lab results, and to keep port patent and clean for dialysis. How does dialysis work to remove waste and fluid from the body? o It restores internal hemostatic by osmosis, diffusion, and ultrafiltration o It extracts toxic wastes from the blood by removing the blood from the body, circulating it through a purifying dialyzer, and then returning to the body. Will this patient require dialysis for the rest of his life? o Patient has multiple comorbidities and may require dialysis for the rest of his life.