Pathophysiology Chapter 34 acute kidney injury and chronic kidney disease

The nurse is educating a client with chronic kidney disease (CKD). What is the recommended daily fluid intake for this client?

A daily fluid intake of 500 to 800 mL/day to maintain hydration Explanation: Daily fluid intake of 500 to 800 mL/day will replace insensible water loss plus a quantity equal to the 24-hour urine output. Intake of 2000 mL will exceed the renal ability to excrete water and will lead to circulatory overload and edema. p903

A client had excessive blood loss and prolonged hypotension during an extensive surgery. The client's postoperative urine output is sharply decreased and the blood urea nitrogen (BUN) is elevated. Which cause is most likely responsible for these abnormal findings?

Acute tubular necrosis Explanation: Ischemic acute tubular necrosis (ATN) occurs most frequently in persons who have major surgery with prolonged renal hypoperfusion—this directly damages the tubular epithelial cells with acute suppression of renal function. Nephrotoxic ATN is caused by toxic agents or drugs. Prerenal vasoconstriction is associated with acute-onset loss of renal output. Bladder (postrenal) obstruction would not affect the BUN, since it rarely causes renal failure. p892

Chronic kidney disease impacts many systems in the body. What is the most common hematologic disorder caused by CKD?

Anemia Explanation: The most common hematologic disorder that accompanies CKD is anemia. p899

As chronic kidney disease progresses, the second stage (renal insufficiency) is identified by:

Decrease in GFR of 60 to 89 mL/minute/1.73 m2 Explanation: Diminished renal reserve is characteristic of renal insufficiency, when labs remain normal but there is renal insufficiency. Only the second stage, formerly known as renal insufficiency, is characterized by a decrease in GFR of 60 to 89 mL/minute/1.73 m2. The other choices represent stage 3, 4, and 5, respectively. p895

A new client presents with elevated BUN, systemic edema, a BP of 145/93 mm Hg, recurrent infections, and a GFR of 51 mL/min/1.73 m2. Which treatment should the nurse anticipate?

Dialysis Explanation: These findings are suggestive of chronic kidney disease (CKD), defined as kidney damage with a GFR less than 60 mL/min/term-21.73 m2 for 3 months or longer. Dialysis is a likely intervention. The disease is noninfectious, so antibiotics are not necessarily indicated. Dialysis would precede a transplant in nearly all circumstances. BMT is not a relevant intervention. p905

A child has received a kidney transplant at the age of 3. Knowing he will be on immunosuppressive agents like corticosteroids, the nurse should educate the parents about which long-term side effects? Select all that apply.

Hypertension Growth retardation Development of cataracts Explanation: Early transplantation in young children is regarded as the best way to promote physical growth, improve cognitive function, and foster psychosocial development. Immunosuppressive therapy in children is similar to that used in adults. All immunosuppressive agents have side effects, including increased risk for infection. Corticosteroids carry the risk for hypertension, orthopedic complications (especially aseptic necrosis), cataracts, and growth retardation. Steroids usually are associated with weight gain. Frequent hematuria is caused by something other than steroids and should be reported. p903

A client diagnosed with CKD has begun to experience periods of epistaxis and has developed bruising of the skin and subcutaneous tissues. The nurse recognizes these manifestations as:

Impaired platelet function Explanation: The coagulation disorders of CKD are mainly caused by platelet dysfunction. Platelet counts may be slightly decreased, and the bleeding time is prolonged because of abnormal adhesiveness and aggregation. Clinically, persons with CKD can experience epistaxis (nosebleeds), menorrhagia (excessive menstrual bleeding), gastrointestinal bleeding, and bruising of the skin and subcutaneous tissues. p899-900

The client with substance use disorder was found unconscious after overdosing on heroin 2 days prior. Because of prolonged pressure on the muscles the client has developed myoglobinuria, causing which complication?

Obstruction of the renal tubules with myoglobin and damaged tubular cells Explanation: Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments. Myoglobinuria causes hyperkalemia, which may cause cardiac dysrhythmias, metabolic acidosis, hyperphosphatemia, early hypocalcemia, and late hypercalcemia. p893

A client with chronic kidney disease has been admitted with increased shortness of breath and abnormal breath sounds (rales heard to scapular region of posterior back). The admission hemoglobin level is 7.8 g/dL. Vital signs are as follows: respiratory rate 30; BP 180/98; pulse 110. +3 pitting edema in lower extremities bilaterally. Knowing the correlation of hypertension and associated anemia, the nurse suspects this client has developed:

heart failure. Explanation: Multiple factors lead to development of left ventricular dysfunction, including extracellular fluid overload, shunting of blood through an arteriovenous fistula for dialysis, and anemia. Anemia, in particular, has been correlated with the presence of left ventricular hypertrophy. These abnormalities, coupled with the hypertension that often is present, cause increased myocardial work and oxygen demand, with eventual development of heart failure. There is no indication that the client has developed pulmonary hypertension, further renal disease, or bone marrow issues. p900