Chapter 42: Acute Renal Failure and Chronic Kidney Disease

Post renal failure

Sudden obstruction of urine flow Examples: Enlarge prostate, stones, tumors

A 35-year-old client is diagnosed with acute kidney injury (AKI) and is started on hemodialysis. The client is concerned with the diagnosis and wants to know what to expect in the progression of this disorder. Which statement best addresses the client's concern?

"Acute kidney injury is abrupt in onset and often reversible if recognized early and treated appropriately." AKI is the result of a rapid decline in kidney function that increases blood levels of nitrogenous wastes. Once the underlying cause is treated, AKI is potentially reversible if the precipitating factors can be corrected or removed before permanent damage occurs.

A patient has prerenal failure. The nurse knows that this type of failure is characterized by which relationship of blood urea nitrogen (BUN) to serum creatinine levels?

A BUN to creatinine level ratio of 20:1 In prerenal failure, glomerular filtration rate (GFR) decreases, allowing more filtered urea to be reabsorbed into the circulatory system. Creatinine is filtered but remains in the forming urine. Thus the BUN to creatinine ratio rises to 20:1. A ratio of 10:1 is normal.

A patient is evaluated for possible acute renal failure. The nurse knows that the most common indicator of acute renal failure is which of the following?

Azotemia

Acute renal failure occurs at a high rate in seriously ill people who are in intensive care units. What is the most common indicator of acute renal failure?

Azotemia and a decrease in the GFR

The nurse is caring for a patient who has had acute blood loss from ruptured esophageal varices. Which of the following does the nurse recognize is an early sign of prerenal failure?

Baseline urine output of 50 mL/hr that is now 10 mL/hr The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.

A client with a long-standing diagnosis of chronic kidney disease has been experiencing increasing fatigue, lethargy, and activity intolerance in recent weeks. His care team has established that his GFR remains at a low, but stable, level. Which of the following assessments is most likely to inform a differential diagnosis?

Blood work for hemoglobin, red blood cells, and hematocrit

A client with a long-standing diagnosis of chronic kidney disease has been experiencing increasing fatigue, lethargy, and activity intolerance in recent weeks. His care team has established that his GFR remains at a low, but stable, level. Which of the following assessments is most likely to inform a differential diagnosis?

Blood work for hemoglobin, red blood cells, and hematocrit Anemia is a frequent, and debilitating, consequence of CKD. The anemia may be due to chronic blood loss, hemolysis, bone marrow suppression due to retained uremic factors, and decrease in red cell production due to impaired production of erythropoietin and iron deficiency. Pancreatic function is not typically affected by CKD, and endoscopic examination is less likely to reveal a cause of fatigue. An infectious etiology is possible and would be informed by white cell assessment, but this is less likely than anemia given the client's complaints

Client and family education regarding peritoneal dialysis should include assessing the client for:

Dehydration that may appear as dry mucous membranes or poor skin turgor Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration caused by excessive fluid removal, hyperglycemia, and hernia. The most serious complication is infection, which can occur at the catheter exit site, in the subcutaneous tunnel, or in the peritoneal cavity. In peritoneal dialysis, a sterile dialyzing solution is instilled through a catheter over a period of approximately 10 minutes. Then the solution is allowed to remain in the peritoneal cavity for a prescribed amount of time. Shunts, fistulas, and artificial dialyzers are associated with hemodialysis, which is usually performed three times weekly

The nurse is instructing a patient with advanced kidney disease (AKD) about a dietary regimen. Which of the following restrictions should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD?

Dietary protein

Intra renal failure

Direct damage to the kidneys Caused by infectious processes (glom. nephritis), medications. Acute tubular necrosis. Rare, but possible proteinuria, sodium fraction greater than 2, Specific gravity of 1.010-1.020, urine osmolality less than 500, tubular/RBC/WBC casts.

Several urine tests can be useful in establishing a diagnosis of acute renal failure (ARF). The nurse must consider that fractional excretion of sodium can be particularly affected by administration of which of the following types of drugs?

Diuretics

Regardless of the cause, chronic kidney disease results in progressive permanent loss of nephrons and glomerular filtration, and renal:

Endocrine functions Chronic kidney disease results in loss of nephrons, tubule, and endocrine functions such as erythropoietin production. Systemic and renal hypertension is commonly an early manifestation of chronic kidney disease, caused by resistance to blood flow through the constricted renal vessels. Tubule hypertrophy is a compensatory response for those destroyed—when the few remaining nephrons are destroyed, renal failure is apparent. Phosphate accumulates in the blood; since it is inversely related to calcium, the levels of which remain chronically low.

The nurse is caring for a patient with chronic kidney disease. The patient has been having a difficult time with managing his blood pressure, and present antihypertensive therapy has been ineffective. Which of the following pharmacological therapies does the nurse anticipate administering for this difficult-to-control blood pressure?

Endothelin blockers

Pre renal failure

Inhibits blood flow to the kidneys Caused by septic shock, hemorrhaging, severe dehydration. Fraction of sodium is less than 1, proteinuria is absent, specific gravity is greater than 1.020, urine sodium concentration is less than 2, urine osmolality is greater than 500 and few hyaline cysts are present.

A client has acute pyelonephritis. The nurse will monitor the client for development of which of the following?

Intrarenal failure Acute pyelonephritis, an active bacterial infection, can cause tubular cell necrosis and intrarenal failure. Acute pyelonephritis does not cause prerenal or postrenal failure or chronic kidney disease unless it is not treated.

Vitamin D metabolism is deranged in clients with chronic kidney disease (CKD). The nurse recognizes that which of the following statements regarding vitamin D is correct?

Kidneys convert inactive vitamin D to its active form, calcitriol. Inactive vitamin D is converted to active calcitriol in the kidneys. Calcitriol enhances gastrointestinal absorption of calcium, and suppresses release of PTH. Elevated levels of PTH are characteristic of CKD as blood levels of phosphate rise and levels of calcium fall

A client with acute tubular necrosis (ATN) exhibits oliguria and edema, and the laboratory results reveal increased levels of urea, potassium, and creatinine. Based on symptoms and lab data, which phase of ATN is this client most likely experiencing?

Maintenance phase The maintenance phase of ATN is characterized by marked decrease in GFR, causing sudden retention of endogenous metabolites, such as urea, potassium, sulfate, and creatinine, that normally are cleared by the kidneys. The urine output is usually lowest at this point. Fluid retention gives rise to edema, water intoxication, and pulmonary congestion. ATN typically progresses through three phases: the initiation phase, during which tubular injury is induced; the maintenance phase, during which the GFR falls, nitrogenous wastes accumulate, and urine output decreases; and the recovery or reparative phase, during which the GFR, urine output, and blood levels of nitrogenous wastes return to normal

The health care provider has prescribed an aminoglycoside (gentamicin) for a client. The nurse is aware that the client is at risk for:

Nephrotoxic acute tubular necrosis Pharmacologic agents that are directly toxic to the renal tubule include aminoglycosides (e.g., gentamicin), cancer chemotherapeutic agents such as cystplastin and ifosfamide, and radiocontrast agents. Nephrotoxic agents cause tubular injury by inducing varying combinations of renal vasoconstriction, direct tubular damage, or intratubular obstruction. Postrenal failure results from obstruction of outflow of the kidneys. CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs. Acute tubular necrosis (ATN) occurs most frequently in clients who have major trauma, severe hypovolemia, overwhelming sepsis, trauma, or burns

A drug abuser was found unconscious after shooting up heroin 2 days prior. Because of the pressure placed on the hip and arm, the client has developed rhabdomyolysis. The nurse knows this can:

Obstruct the renal tubules with myoglobin and damage tubular cells

Which symptom occurs in a client with chronic kidney disease (CKD) as a result of elevated serum phosphate levels and the development of phosphate crystals that occur with hyperparathyroidism?

Pruritus Pruritus is common in persons with CKD; it results from high phosphate levels and the development of phosphate crystals. Azotemia refers to elevated levels of nitrogenous wastes in the blood. Uremia is the accumulation of organic wastes in the blood. Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea

The GFR is considered to be the best measure of renal function. What is used to estimate the GFR?

Serum creatinine

An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which of the following early signs of prerenal injury?

Sharp decrease in urine output

A patient with chronic kidney disease (CKD) will be managed with peritoneal dialysis. The nurse will give the patient which of the following descriptions of this type of dialysis?

Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time. In peritoneal dialysis, a sterile dialyzing solution is instilled into the peritoneum through a catheter over approximately 10 minutes. The solution remains ("dwells") in the peritoneal cavity for a determined time interval, then drains into a sterile bag. Shunts, fistulas, and artificial dialyzers are associated with hemodialysis, which is usually performed three times weekly. The frequency of peritoneal dialysis varies, but is normally performed more often than hemodialysis and can be done at home.

Both high-turnover and low-turnover renal osteodystrophy, the skeletal complications of chronic kidney disease, are manifested by abnormal _________ and defective bone __________.

absorption; remodeling Both types of renal osteodystrophy are manifested by abnormal absorption and defective bone remodeling. Bone surface becomes hypocellular (low-turnover type only) and elevated parathyroid hormone (PTH) is associated with high turnover type only. Abnormal matrix density is present (high turnover type only), but bone marrow changes are not a feature of osteodystrophy. Bone shape is not affected by osteodystrophy. Although it can cause muscle weakness that affects movement, joint motion is unaffected.

Anemia frequently occurs in clients with chronic kidney disease (CKD). The nurse will monitor these clients for which of the following contributors to anemia? Select all that apply.

• Decreased erythropoietin production • Anorexia • Bone marrow suppression • Chronic blood loss

The nurse is providing care for a patient with a diagnosis of kidney failure. Which of the following laboratory findings is consistent with this patient's diagnosis? Select all that apply.

• Hypocalcemia • Albuminuria • Reduced calcitriol Diagnostic findings consistent with a diagnosis of kidney failure include albuminuria, metabolic acidosis, hyperphosphatemia, hyperkalemia, and hypocalcemia. Levels of calcitriol are reduced as the kidneys lose their ability to regulate vitamin D activation.

The nurse knows that a patient with chronic kidney disease (CKD) may experience which of the following changes in skin integrity? Select all that apply.

• Pale skin • Brittle fingernails • Decreased perspiration In CKD, anemia due to loss of erythropoietin activity causes pale skin. Perspiration and oil secretion are decreased, leading to dry skin. Fingernails become brittle.

Uremic pericarditis is a disorder that accompanies CKD. What are its presenting signs and symptoms? (Select all that apply.)

• Pericardial friction rub • Chest pain with respiratory accentuation • Fever without infection

A client with chronic kidney disease (CKD) is anemic. The nurse will attempt to alleviate the anemia in order to prevent which of the following? Select all that apply.

• Tachycardia • Fatigue • Decreased myocardial oxygen Uncorrected anemia provokes fatigue and insomnia, a decrease in blood viscosity, a decrease in myocardial oxygen supply, and tachycardia as the heart attempts to supply sufficient oxygen to the heart and brain.

A client is suspected to have renal disease. The nurse would suggest which of the following determinations to confirm this diagnosis? Select all that apply.

• Urinary sediment of red and white cells • Ultrasonography • Measurement of cystatin C • Imaging studies