4800 Week 7 Renal Student

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Acute Kidney Injury Acute Kidney Injury and Chronic Kidney and Chronic Kidney

DiseaseDisease

Challenge Question

• A patient is concerned about her steadily worsening chronic kidney disease and asks you at what point she will require dialysis. Which of the following should you mention?

Challenge Question

• A patient is concerned about her steadily worsening chronic kidney disease and asks you at what point she will require dialysis. Which of the following should you mention?

• A. when urine albumin to Cr ratio is great than 25• B when your urine output is less than 0.5 ml/kg/h x 6 hours• C. when your GRF falls below 15mL/min/1.73m2• D. When your urine osmolality is greater than 500

Challenge Question

• A patient with chronic kidney disease is receiving an ACE inhibitor. The nurse understands that this medication helps slow the progression of this disease through what process?

Challenge Question

• A patient with chronic kidney disease is receiving an ACE inhibitor. The nurse understands that this medication helps slow the progression of this disease through what process?

• A. It lowers the level of the blood glucose• B. It prevents nerphon hyperfiltration• C. It increases the urine output• D. It filters waste from the blood.

Challenge Question

• A patient with chronic kidney disease has a serum K of 5 and no changes on the ECG. What is the proper nursing intervention?

Challenge Question

• A patient with chronic kidney disease has a serum K of 5 and no changes on the ECG. What is the proper nursing intervention?

• A. Administer sodium polystyrene as an enema• B. Administer IV calcium gluconate• C. Administer IV insulin and dextrose• D. Being dialysis

Challenge Question

• A patient with a history of diabetes mellitus has had a procedure using radiocontrast dye. The patient's laboratory results include high urine sodium, urine with muddy-brown granular casts and tubular epithelial cells, and increased blood urea nitrogen (BUN) and serum creatinine. Renal ultrasonography is normal. Urine volume is normal. Which treatment does the nurse anticipate?

Challenge Question

• A patient with a history of diabetes mellitus has had a procedure using radiocontrast dye. The patient's laboratory results include high urine sodium, urine with muddy-brown granular casts and tubular epithelial cells, and increased blood urea nitrogen (BUN) and serum creatinine. Renal ultrasonography is normal. Urine volume is normal. Which treatment does the nurse anticipate?

• A. increased fluids• B. renal stent placement• C. irrigation of Foley catheter• D. Diuretics

Challenge Question

• A patient has just been diagnosed with type 2 diabetes mellitus. During teaching, what strategy should the nurse emphasize as protective of kidney cells?

Challenge Question

• A patient has just been diagnosed with type 2 diabetes mellitus. During teaching, what strategy should the nurse emphasize as protective of kidney cells?

• A. Monitoring glycosylated hemoglobin every 3 months• B. Strict adherence to prescribed weight-loss diet• C. Restriction of sodium-containing beverages and food• D. Strict control of serum glucose levels with diet and medication

Challenge Question

• A patient with chronic renal disease is involved in a motor vehicle crash and experiences severe hypovolemia. In caring for this patient in the CCU, which of the following is the most important for the nurse to monitor?

Challenge Question

• A patient with chronic renal disease is involved in a motor vehicle crash and experiences severe hypovolemia. In caring for this patient in the CCU, which of the following is the most important for the nurse to monitor?

• A. Blood pressure• B. Fluid volume recovery• C. Urine output• D. Cardiac dysrhythmias

Challenge Question

• A patient with chronic renal failure also has chronic anemia, arteriosclerotic disease, and diabetes mellitus. The patient asks the nurse why the anemia is persisting. In answering the patient's question, what should the nurse most consider?

Challenge Question

• A patient with chronic renal failure also has chronic anemia, arteriosclerotic disease, and diabetes mellitus. The patient asks the nurse why the anemia is persisting. In answering the patient's question, what should the nurse most consider?

• A. The patient most likely has preexisting chronic anemia• B. Erythropoietin is primarily produced in the kidney.• C. The patient is receiving low-dose aspirin therapy.• D. Chronic renal failure results in persistent uremia.

Challenge Question

• Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the

Challenge Question

• Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the

• A. BUN and Cr• B. blood glucose• C. bowel sounds• D. level of consciousness LOC

28. The nurse assesses the progress of a client diagnosed with acute glomerulonephritis. The nurse is MOST concerned by which finding?

1. Hematuria. 2. Proteinuria.3. Fixed urine specific gravity.4. Urine excretion of 1,500 mL in 24 hours.

Acute Kidney InjuryAcute Kidney Injury

• Etiology and PathophysiologyEtiology and Pathophysiology• PrerenalPrerenal• IntrarenalIntrarenal• PostrenalPostrenal

1. The nurse determines that a patient with oliguria has oliguria of intrarenal acute kidney injury when

1. the serum creatinine level is normal.2. urine testing reveals a specific gravity of 1.010.3. urine testing reveals a low concentration of sodium.4. reversal of the oliguria occurs with fluid replacement.

RIFLE Classification

• Risk• Injury• Failure• Loss• End-stage kidney disease

AKI Clinical Manifestations

• Oliguric phase• Urinary changes• Fluid volume • Metabolic acidosis• Sodium balance

• Oliguric phase• Potassium excess: ECG changes: next slide• Hematologic disorders• Waste product accumulation• Neurologic disorders

ECG Changes in Hyperkalemia

• Diuretic Phase• 5 L/day• Hypovolemia• Hypotension• Hyponatremia• Hypokalemia• Dehydration

• Recovery Phase• GFR increases• BUN , Cr: plateau, decrease

Acute Kidney Injury: Acute Kidney Injury: Diagnostic Diagnostic StudiesStudies

• HistoryHistory• Urine outputUrine output• Serum CrSerum Cr• UAUA• UltrasoundUltrasound• CTCT• MRIMRI• MRAMRA

Acute Kidney Injury: Acute Kidney Injury: CollaborativeCollaborative

• Volume status Volume status • Fluid restriction (600 + previous 24 hours)Fluid restriction (600 + previous 24 hours)• Diuretic therapyDiuretic therapy• I & OI & O• HyperkalemiaHyperkalemia

Acute Kidney Injury: Acute Kidney Injury: HyperkalemiaHyperkalemia

• Regular Insulin IVRegular Insulin IV• Sodium BicarbonateSodium Bicarbonate• Calcium Gluconate IVCalcium Gluconate IV• HemodialysisHemodialysis• Sodium polystyrene sulfonateSodium polystyrene sulfonate• Dietary restrictionDietary restriction

Acute Kidney Injury: Acute Kidney Injury: RRT RRT indicationsindications

• Volume overloadVolume overload• Elevated KElevated K• Met Acid: HCO3 < 15Met Acid: HCO3 < 15• BUN > 120BUN > 120• Mental status changesMental status changes• Pericarditis, pericardial effusion, cardiac tamponadePericarditis, pericardial effusion, cardiac tamponade

Acute Kidney Injury: Acute Kidney Injury: Nutritional Nutritional therapytherapy

• Adequate protein : 0.6 – 2g/kg/dayAdequate protein : 0.6 – 2g/kg/day• Calories: 30 – 35kcal/kgCalories: 30 – 35kcal/kg• Protein 0.8 – 1.0 g/kgProtein 0.8 – 1.0 g/kg

• Potassium restrictionPotassium restriction• Sodium restrictionSodium restriction• Phosphate restrictionPhosphate restriction

Nursing Management:Nursing Management:Acute Kidney Injury Acute Kidney Injury

• Nursing Assessment Nursing Assessment • Nursing DiagnosesNursing Diagnoses• PlanningPlanning• Nursing ImplementationNursing Implementation

• Health promotionHealth promotion• Acute interventionAcute intervention• Ambulatory and home careAmbulatory and home care

• EvaluationEvaluation

Gerontologic Considerations: Gerontologic Considerations: Acute Renal Failure Acute Renal Failure

-Dehydration-Hypotension- Diuretic therapy-Aminoglycoside therapy-Prostatic hyperplasia-Surgery-Infection-Contrast agents

Chronic Kidney DiseaseChronic Kidney Disease

43. An elderly client says to the nurse, “I have no energy and it has gotten worse in the last several weeks.” The client has a history of glomerulonephritis and has been taking antacids frequently for the past 2 months. What is the most appropriate FIRST action by the nurse?

1. Assess bilateral deep tendon reflexes.

2. Assess for the presence of Trousseau and Chvostek signs.

3. Listen to bowel sounds in all 4 quadrants for 2 to 3 minutes.

4. Ask the client if urine output has decreased during the last week.

23. An elderly client is brought by the spouse to the clinic. The nurse notes the client has a 10-year history of chronic renal failure and has been taking over the counter cimetidine (Tagamet) for 2 weeks. It is MOST important for the nurse to investigate which statement made by the client’s spouse?

1. “My spouse seems to have diarrhea more often since starting this medication.”

2. “My spouse takes Maalox and Tagamet together.”

3. “My spouse seems to be having more trouble remembering things lately.”

4. “My spouse reports a headache after reading the newspaper.”

Chronic Kidney Disease : CausesChronic Kidney Disease : Causes

• Diabetes 50%Diabetes 50%• Hypertension 25%Hypertension 25%• GlomerulonephritisGlomerulonephritis• Cystic diseases Cystic diseases • Urological diseasesUrological diseases

Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations

• Urinary SystemUrinary System

• MetabolicMetabolic

• Electrolyte & Acid-base ImbalancesElectrolyte & Acid-base Imbalances

• HematologicalHematological

• AnemiaAnemia• Bleeding tendenciesBleeding tendencies• InfectionInfection

• CardiovascularCardiovascular

• RespiratoryRespiratory

• GIGI

• NeurologicalNeurological

• MusculoskeletalMusculoskeletal

• IntegumentaryIntegumentary

• ReproductiveReproductive

• PsychologicalPsychological

Chronic Kidney Disease: Chronic Kidney Disease: Diagnostic StudiesDiagnostic Studies

• UA: dipstick: UA: dipstick: • ProteinProtein

• Microanalysis: microalbuminuriaMicroanalysis: microalbuminuria

• RBC, WBC, castsRBC, WBC, casts• BUNBUN• CrCr• GFRGFR

Chronic Kidney Disease: Chronic Kidney Disease: Collaborative Care

• Drug therapy • Hyperkalemia• Hypertension• CKD—mineral and bone disease• Anemia• Dyslipidemia• Complications of drug therapy

Chronic Kidney Disease: Chronic Kidney Disease: Collaborative Care

• Nutritional therapy • Protein restriction• Water restriction• Sodium and potassium restriction

Nutritional Therapy

• Phosphate restriction• 1000 mg/day• Foods high in phosphate

• Dairy products • Most foods high in phosphate are also high in

protein.

When teaching a patient with chronic kidney disease about prevention of complications, the nurse instructs the patient to:

Challenge Question

When teaching a patient with chronic kidney disease about prevention of complications, the nurse instructs the patient to:

1. Monitor for proteinuria daily with a urine dipstick.2. Weigh daily and report a gain of greater than 4 pounds.3. Take calcium-based phosphate binders on an empty stomach.4. Perform self-catheterization every 4 hours to accurately measure I & O.

Challenge Question

Nursing Management:Nursing Management:Chronic Kidney DiseaseChronic Kidney Disease

• Nursing AssessmentNursing Assessment• Nursing Diagnoses Nursing Diagnoses

DialysisDialysis

• Hemodialysis HDHemodialysis HD• Peritoneal dialysis PDPeritoneal dialysis PD

Peritoneal Dialysis Peritoneal Dialysis

• https://www.youtube.com/watch?v=CDBNmgkIqMs

29. The nurse cares for a client receiving hourly peritoneal dialysis exchanges. During a 1-hour exchange, the nurse infuses 2000 mL of dialysate, and 1900 mL of outflow is returned. During the exchange, the client drinks 8 oz of apple juice and 2 cups of water and voids 150mL of urine. Calculate and record the client’s intake in milliliters.

When implementing care for the patient on peritoneal dialysis, the nurse recognizes that dietary needs include an increased amount of

1. fat2. protein3. calories4. carbohydrates

Peritoneal DialysisPeritoneal Dialysis

• Automated peritoneal dialysis APDAutomated peritoneal dialysis APD

• Continuous ambulatory peritoneal dialysis CAPDContinuous ambulatory peritoneal dialysis CAPD

Fig. 47-6. Peritoneal catheter exit site.

• Dialysis Solutions and Cycles: 4 per day• Exchange

• Inflow• Dwell• Drain

• Complications

• Infection: catheter exit site• Peritonitis• Pain

• Hernias• Lower back pain• Protein loss

• Continuous ambulatory peritoneal dialysis

32. The nurse counsels a client undergoing continuous ambulatory peritoneal dialysis (CAPD). The nurse determines that further teaching is necessary if the client makes which statement?

1. “I need to restrict driving and other outdoor activities when the fluid is in my abdomen.”

2. “I can continue my normal activities immediately after the fluid has drained from my abdomen.”

3. “I will need to follow a low-protein diet while receiving this treatment.”

4. “I might have to buy larger size clothing.”

Hemodialysis Hemodialysis

• Vascular Access Sites• Arteriovenous fistulas AVF• Arteriovenous grafts AVG

• 3 days per week: 3 – 4 hours

• Assessment• Weight• BP• Peripheral edema• Lung sounds• Heart sounds• Vascular access• Temp• Skin

• Complications:

• Hypotension• Muscle cramps• Blood loss• Hepatitis

Continuous Renal Replacement Continuous Renal Replacement Therapy Therapy

Kidney Transplantation Kidney Transplantation

• Survival rates

• Contraindications• Disseminated malignancies• Refractory or untreated cardiac disease• Chronic respiratory failure• Extensive vascular disease• Chronic infection• Unresolved psych disorders

Kidney Transplantation Kidney Transplantation

• Recipient Selection• Compatible blood type deceased• Blood relatives• Emotionally related living donors• Altruistic living donors

• Histocompatibility Studies

Six days following a deceased donor kidney transplant, the patient develops a temperature of 101.2° F (38.5° C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate

1. acute rejection, which is not uncommon and is usually reversible.

2. hyperacute rejection, which will necessitate removal of the transplanted kidney.

3. an infection of the kidney, which can be treated with intravenous antibiotics.

4. the onset of chronic rejection of the kidney with eventual failure of the kidney.

Nursing Management: Nursing Management: Kidney Transplant Recipient Kidney Transplant Recipient

• Preoperative CarePreoperative Care• Postoperative Care Postoperative Care

• Fluid and electrolyte balanceFluid and electrolyte balance• InfectionInfection• SurgerySurgery

• Immunosuppressive TherapyImmunosuppressive Therapy

Nursing Management: Nursing Management: Kidney Transplant Recipient Kidney Transplant Recipient

• Complications of Transplantation • Rejection • Infection• Cardiovascular disease• Malignancies: 100% greater than general population: immunosuppression• Recurrence of original renal disease• Corticosteroid-related complications

4800 Week 7 Renal Student

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