Acute Kidney Injury • Rapid loss of kidney function, Exams of Nursing

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HLTH 4000 WEEK 3 EXAM – 100 OUT OF 100 Acute Kidney Injury • Rapid loss of kidney function • Loss is accompanied by a rise in serum creatinine above 1.3 and/or a reduction in urine output Lab normal values: Urea nitrogen (BUN) (mg/dL 8–20 mg/dL Creatinine (mg/dl) 0.6-0.7 –1.3 mg/dL Pathophysiology: • Increase in BUN (will go higher than 30 mg/dL) • Can develop over hours to days Prerenal: • Factors that reduce systemic circulation, causing a reduction in renal blood flow • Decrease in blood flow leads to decreased glomerular perfusion and filtration of the kidneys Intrarenal: • Condition that cause direct damage to the kidney tissue, resulting in impaired nephron function • Acute tubular necrosis (ATN) is the most common intrarenal cause Postrenal: • Involve mechanical obstruction in the outflow of urine • Urine refluxes into the renal pelvis, impairing kidney function • Common cause are benign prostatic hyperplasia (BPH), prostate cancer, stones, trauma, and extrarenal tumors Clinical Manifestations: RIFLE Classification • Risk • Injury • Failure • Loss • End-Stage kidney disease Oliguric Phase: • Urinary changes • Urinary output less than 400 mL. per day • Occurs within 1 to 7 days after injury • Lasts 10 to 14 days • Urinalysis may show casts, RBCs, WBCs Diuretic Phase: • Urine output is usually around 1 to 3 L but may reach 5L or more • Hypovolemia and hypotension can occur from massive fluid losses • Near end of the phase, the patient’s acid-base, electrolyte, and waste product (BUN, creatinine) values stabilize Recovery Phase: • Begins when glomerular filtration rate (GFR) increases, allowing the BUN and serum creatinine levels to decrease GFR - determines kidney function and if hemodialysis is required. Normal GFR level: 85-135 • Improvements occur in the first 1 to 2 weeks • Kidney function may take up to 12 months to stabilize • Include how to recognize signs of: o Rejection, infection, and any complications • Frequent blood tests • Clinic visits helps to detect rejection early Recipient Criteria: • Determine by a variety of medical and psychosocial factors • Some transplant programs exclude patients who are morbidly obese or continue to smoke • Patients with Cerebrovascular Disease (CVD) and diabetes are considered high risk • Contraindication to transplantation include: o Advanced cancer o Refractory or untreated heart disease o Chronic respiratory failure o Extensive vascular disease o Chronic infection o Unresolved psychosocial disorders Who are the contraindicated for kidney transplant? Substance abuse Cardiac disease Psychosocial disorders Disseminated malignancies CRF - chronic renal failure Vascular disease Chronic infection, due to higher chance of the body rejecting the kidney Live Donor Criteria: • Undergo extensive evaluation to ensure they are in good health and have no history of disease • Blood crossmatches are done at time of evaluation o To ensure that no antibodies to the donor are present or that the antibody titer is below the allowed level • Sees a nephrologist for a complete history and physical examination and lab and diagnostic studies o 24-hour urine study for creatinine clearance and total protein o CBC o Chemistry and electrolyte profiles • Hep B and C, HIV, testing to assess transmitted disease • ECG and chest x-ray • Transplant psychologist or social worker determines if the person is emotionally stable and able to deal with the issues related to organ donation Hemodialysis • Requires a very rapid blood flow and access to a large blood vessel • Types of vascular access include: o Arteriovenous fistulas, AV grafts and temporary vascular access • With a machine, attached to access Arteriovenous fistula • Normal saline to up blood pressure Arteriovenous Assessment: • AVF should be placed at least 3 months before starting Hemodialysis • A fistula is the preferred access for Hemodialysis • Thrill (buzzing sensation) can be felt by palpating the fistula • Bruit (rushing sound) can be heard with a stethoscope What does the nurse assess Arteriovenous fistula in the patients dialysis site? Feel for thrill & hear the bruit." Thrill is a vibration, bruit is a 'whooshing' sound. Complications: • Hypotension • Muscle cramps • Loss of blood • Hepatitis Dialysis equilibrium syndrome o Can occur during and after o Range of neurological symptoms that affect patients of hemodialysis ▪ Headache ▪ Seizures ▪ Coma ▪ Restlessness ▪ Nausea and Vomiting ▪ Cerebral edema o Should administer Dilatin (Phenytoin) if patients report any of these signs and symptom. Labs: • Assess fluid status o Weight, Blood pressure before hemodialysis, peripheral edema, lung and heart sounds • Condition of vascular access and temperature • Difference between the last post dialysis weight and the present pre-dialysis weight o Determined the ultrafiltration or the amount of weight (from fluid (to be removed) • Take vital signs every 30 to 60 minutes o Rapid BP changes occur Patient Teaching: Did not find What are the complications of HD? What is the treatment? Hypotension, Loss of blood, Lethargy Disequilibrium Syndrome pre and post treatment If Syndrome occurred S&S: restlessness, seizure, & headache. Treated with Dilantin to prevent status epilepticus. Complications of Hemodialysis: Disequilibrium syndrome -> Use a slow dialysis exchange rate, especially for older adult clients and those being treated with hemodialysis for the first time. A patient going about to get hemodialysis, how do you determine if the pt has fluid overload? Look at the pt. weight gains as weights are taken daily. Note: If pt. gains 4-5lbs in one day; contact HCP. What is the biggest issue in hemodialysis? What are the common access sites? What is an expected finding post dialysis? Finding an easily accessible vascular access site. Commonly accessed through the neck, or wrist. Hypokalemia & hyponatremia Peritoneal Dialysis • Obtained by inserting a catheter through the anterior abdominal wall • Usually done via surgery • If the patient complains of abdominal pain, do not stop the infusion just slow it down Inflow: • A prescribed amount of solution, usually 2L is infused through an established catheter over about 10 minutes • Flow rate may be decreased if the patient has pain • After the solution has been infused, the inflow clamp is closed • What are the 3 phases of the Peritoneal Dialysis cycle and what can the patient expect? inflow - Teach the patient to expect slight abdominal pain during the first few weeks of therapy. Dwell: • Also known as equilibration • Diffusion and osmosis occur between the patient’s blood and peritoneal cavity • Duration is usually between 4 and 6 hours • Can let the patient know to move side to side to let the solution flow Drain phase: • Lasts 15 to 30 minutes • May be facilitated by gently massaging abdomen or changing position • May see purulent drainage indicating an infection Drain - Lasts 15-30 minutes. Purulent during draining indicates infection Systems: • Automated peritoneal dialysis o Cycler delivers dialysate o times and controls fill, dwell, and drain • Continuous ambulatory peritoneal dialysis (CAPD) o Manual exchange o Requires fewer dietary restrictions than hemodialysis, due to increases in frequency What are the 2 types of PD and what is the advantage compared to hemodialysis? 1. Continuous ambulatory Peritoneal dialysis - Manual exchange that requires fewer dietary restrictions compared to hemodialysis due to the increase in frequency. 2. Automated Peritoneal Dialysis (APD) - Automated processes What is the benefit of Peritoneal dialysis over hemodialysis? There are fewer dietary restrictions for this treatment, there's more freedom. Dialysate Preparation Solution: Hanging it up Slight ABD pain may be expected with this phase during the first few weeks of therapy • The importance of reporting any of the following: weight gain, increasing blood pressure, SOB, edema, increasing fatigue or weakness, or confusion or lethargy • Need for support and encouragement • Reasons for prescribed drugs and common side effects: o Phosphate binders (including calcium supplements used as phosphate barriers) should be taken with meals o Take calcium supplements prescribed to treat hypocalcemia on an empty stomach, but not at the same time as iron supplements. o Iron supplements should be taken between meals. Questions to practice: https://quizlet.com/535382675/201-quiz-6-review-by-topic-aki-and-ckd-flash-cards/ https://quizlet.com/534828458/201-quiz-6-focused-review-aki-and-ckd-flash-cards/ 1. During the oliguric phase for someone who has acute kidney injury AKI, what should you usually see for this patient’s urine output? - Urinary output less than 400 mL/day Potential complication: dysrhythmia Note: This is due to elevated potassium levels in the oliguric phase - hyperkalemic. What is the normal urine out for 24 hrs? - 400 mL 2. When we’re looking at patients with an AKI, what elevations do you usually notice with the patient when we look at their blood metabolic panel? - We are going to see elevations in the BUN and SERUM CREATININE 3. What electrolyte imbalances are very evident/most likely occurred with someone with an Acute Kidney Injury? - High potassium - Hyperkalemia and hyponatremia 4. What is contraindicated for someone getting a kidney transplant? ETOH/ Drug use (alcohol) Substance abuse Chronic respiratory infections 5. How do I know someone is having an acute reaction / rejection right after a kidney transplant, what can I monitor for this patent? of S&S will we see? (when looking at urine output) - If the patient is developing oliguria - If the patient becomes anuric (no urine output) - This shows that the kidney is showing some type of acute rejection - An immediate sign of rejection may be apparent as inability to void or oliguria 6. What are some signs and symptoms of someone who is having dialysis/equilibrium syndrome? What are some signs and clinical manifestations of this? - Restlessness - Headaches - Seizures - Nausea/Vomiting - Coma 7.) Dialysis Equilibrium Syndrome (can occur during and after dialysis) ▪ Restlessness ▪ Nausea and vomiting ▪ Headache ▪ Cerebral edema ▪ Seizures ▪ Coma ▪ Should administer Dilatin (Phenytoin) if patient reports any of these symptoms 8.) What is the treatment that we give for patients experiencing these clinical manifestations? Should administer Dilatin (Phenytoin) if patient reports any of these S/S 9.) If I am sending someone to hemodialysis, what electrolytes is most likely going to be decreased following hemodialysis? What is the biggest issue in hemodialysis? What are the common access sites? What is an expected finding post dialysis? • Potassium What is the most critical fluid electrolyte in Acute Kidney Injury? Why is this relevant? High Potassium levels (hyperkalemia) are the most critical electrolyte It causes cardiac issues e.g. arrhythmia/dysrhythmia. Finding an easily accessible vascular access site. Commonly accessed through the neck, or wrist. Hypokalemia & hyponatremia 10.) When we’re having patients go home with peritoneal dialysis, this is something we need to tell them, especially talk to the patient about patient education. How do you want the patient to warm their dialysate? -This has to be warmed room temperature before it goes into the patient - Heating pad - Do not put in a microwave (if patient said: “I would put in microwave to warm it up” he needs further teaching) - Can warm unevenly 11.) What would be really concerning, or how would I know my patient is experiencing fluid overload (hypervolemia)? • Patient would gain weight, any type of extreme weight gain (4 to 5 pounds in one day/ 24 hour) • Reason why we always want the patient to do their daily weight 12.) If we’re sending someone home on peritoneal dialysis for the first time, what do you want to make sure you first tell them, especially during that first phase/Inflow phase of dialysis, what could happen? - Can experience abdominal pain especially during the first few weeks of therapy A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? A. The patient has an outflow volume of 1800 mL. B. The patient's peritoneal effluent appears cloudy. C. The patient has abdominal pain during the inflow phase. D. The patient's abdomen appears bloated after the inflow. Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient. 13.) Know the acid base imbalance for chronic kidney disease patients? - Metabolic acidosis (Results from Inability of kidneys to excrete acid load (primary ammonia) and defective reabsorption or regeneration of bicarbonate) - pH acidic less than 7.35, bicarb HCO3 is acidic - pH less than 7.35, bicarb HCO3 less than 22 14.) What dietary recommendations do we make for the clients who have chronic anemia who are receiving erythropoietin? What are we trying to ask the patient to add into their diet? • Iron(do not take with Ca) What is a patient teaching for ecotine alpha, epocrit, epogen? Increase iron intake 15.) Know foods high in potassium: - Bananas - Cantaloupe - Tomatoes - Avocados - Raisins (dry fruits) - Potatoes - Green leafy vegetables Why should we restrict food high in potassium? Due to life-threatening arrhythmias. Avoid high potassium foods such as bananas, cantaloupe, green leafy vegetables, raisins & tomatoes. 16.) What are some things we want patients to restrict if they have chronic kidney disease? Other than potassium? - Sodium (Because sodium contains potassium chloride) - Phosphorus - Potassium - Magnesium (Magnesium hydroxide) Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD. - Protein - Calcium is the only electrolyte we want to leave and not mess with everything else we want to decrease (Calcium does not need to be restricted) - Be careful with limiting patients’ calories because they will typically be malnourished (keep high-caloric diet) 17.) For patient education, what do we want to tell the patient about weighing themselves? Nursing interventions for acute intervention for a patient with chronic kidney failure? - We need to emphasize daily weight after patient voided, before breakfast - Same time every day a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function. 29. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. Potassium level. b. Total cholesterol. c. Serum phosphate. d. Serum creatinine. 30. A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate). What group of people are at higher risk for AKI? Elderly What is a priority intervention for a patient w/ serum potassium level of 6.8? (hyperkalemia) Put them on EKG 31. A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for the most recent potassium level. d. Check the chart for the patient's current creatinine level. The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening dysrhythmias. 32. The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be: a. augmenting fluid volume. b. Maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension. The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct. 33. A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine volume B. Calcium level C. Cardiac rhythm D. Neurologic status The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate. Focus on dysrhythmia in hyperkalemic patients. 34. A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis. Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN. 35. During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check the patient's blood pressure (BP) c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs. The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained. 36. What drugs treat hyperkalemia? IV Insulin to manage hypoglycemia. IV 10% calcium gluconate, Sodium polystyrene sulfonate (Kayexalate). Always check patients K+. If critical. Dialysis. 37. Which serum laboratory value indicates to the nurse that is the patient's CKD getting worse? a. Decreased BUN b. Decreased sodium c. Decreased creatinine d. Decreased calculated glomerular filtration rate (GFR) As GFR decreases, BUN and serum creatinine levels increase. Although elevated BUN and creatinine indicate that waste products are accumulating, the calculated GFR is considered a more accurate indicator of kidney function than BUN or serum creatinine. 38. During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of: a. angina. b. asthma. c. hypertension d. rheumatoid arthritis. 39. What is the most serious electrolyte disorder associated with kidney disease? a. Hypocalcemia b. Hyperkalemia c. Hyponatremia d. Hypermagnesemia 40. What is a cause of concern with dialysis? It causes a drop in BP (hypotension). Also, potassium must be restricted to prevent hyperkalemia. 41. A patient rapidly progressing toward end-stage kidney disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that what is a contraindication to kidney transplantation? a. Hepatitis C infection b. Coronary artery disease c. Refractory hypertension d. Extensive vascular disease Because adequate blood supply is essential for the health of the new kidney. Other contraindications include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, chronic infection, or unresolved psychosocial disorders. Coronary artery disease (CAD) may be treated with bypass surgery before transplantation and transplantation can relieve hypertension. Hepatitis B or C infection is not a contraindication. 42. A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality? a. Infection b. Rejection c. Malignancy d. Cardiovascular disease Infection is a significant cause of morbidity and mortality after transplantation because the surgery, the immunosuppressive drugs, and the effects of CKD all suppress the body's normal defense mechanisms, thus increasing the risk of infection. The nurse must assess the patient as well as use aseptic technique to prevent infections. Rejection may occur but for other reasons. Malignancy occurrence increases later due to immunosuppressive therapy. Cardiovascular disease is the leading cause of death after renal transplantation but this would not be expected to cause death within the first month after transplantation.