NURS 405 Acute Kidney Injury & dialysis

What is a characteristic of the intrarenal category of acute renal failure? Decreased creatinine Increased BUN High specific gravity Decreased urine sodium

Increased BUN Explanation: The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.

what are clinical manifestations of AKI in children?

- edema - decreased/ no urine output - hematuria - hypertension - labs: high serum creatinine, high BUN, hyperkalemia

what are signs of fluid overload in AKI?

- edema - hypertension - heart failure - pulmonary edema

causes of postrenal AKI

Usually due to obstruction distal to kidney b/c of renal calculi, structures, blood clots, BPH, malignancies, and pregnancy

Kayexalate

aka sodium polystyrene sulfonate exchanges sodium ions for potassium ions in the intestinal tract indicated for treatment of AKI

what are prerenal causes of AKI?

Caused by impaired blood flow due to - volume depletion (burns, hemorrhage, GI losses) - Hypotension (sepsis, shock) - Renal artery stenosis - Heart failure or shock

what are signs of intravascular volume depletion in AKI?

-tachycardia -delayed cap refill -low BP -weak peripheral pulses -dry mucous membranes

what are the phases of AKI?

1. Oliguria - Increase in serum concentration of substances the kidneys usually excrete - Hyperkalemia can develop Can be life-threatening 2. Diuresis - Increase in urine output, signaling GFR is beginning to recover - Dehydration is a potential complication 3. Recovery - May take 3 to 12months - Lab value return to normal - 1 - 3% permanent reduction in GFR may occur

causes of AKI

A decrease in kidney perfusion due to: - hypovolemia/ volume depletion (e.g., hemorrhage, vomiting, diarrhea, burns) - hypotension (sepsis, shock) - Reduced cardiac output and heart failure - Obstruction of the kidney or lower urinary tract by tumor, blood clot, or kidney stone - Bilateral obstruction of the renal arteries or veins

what are criteria for AKI from the National Kidney Foundation?

- 50% or greater increase in serum creatinine above baseline (normal creatinine is less than 1 mg/dL) w/in 7 days, or - Increase in SCr by at least 0.3 mg/dL w/in 2 days, or - Oliguria

A client with chronic renal failure comes to the clinic for a visit. During the visit, he complains of pruritus. Which suggestion by the nurse would be most appropriate? "Try washing clothes with a strong detergent to ensure that all impurities are gone." "When you shower, use really warm water and an antibacterial soap." "Keep your showers brief, patting your skin dry after showering." "Liberally apply alcohol to the areas of your skin where you itch the most."

"Keep your showers brief, patting your skin dry after showering." Explanation: The client with pruritus needs to keep the skin clean and dry. The client should take brief showers with tepid water, pat the skin dry, use moisturizing lotions or creams, and avoid scratching. In addition, the client should use a mild laundry detergent to wash clothes and an extra rinse cycle to remove all detergent or add 1 tsp vinegar per quart of water to the rinse cycle to remove any detergent residue.

what does nutritional therapy entail for AKI?

- High carbohydrate meals b/c they have a protein-sparing effect (protein is not used for energy and is spared for growth/ tissue healing) - Potassium or phosphorous is restricted

who is at risk for AKI?

- patients on nephrotoxic medications - anything that reduces renal blood flow: ---> heart failure --> increased age --> NSAIDs can damage kidneys --> dehydration

The nurse is caring for a patient in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: Hypernatremia. Hypokalemia. Hyperkalemia. Hypercalcemia.

Hyperkalemia. Explanation: Hyperkalemia is a common complication of acute renal failure. It is life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.

What kind of AKI would NSAIDs cause? (prerenal, renal, or postrenal)

NSAIDs --> renal vasoconstriction --> prerenal

what are the 3 categories of AKI?

Prerenal - caused by hypoperfusion Intrarenal - injury to the kidney itself Postrenal - usually obstructive

what is the classification system for AKI?

RIFLE R - risk I - injury F - failure L - loss E - end-stage kidney disease

what are imbalances seen in AKI? Which is the most life-threatening imbalance seen in AKI?

hyperkalemia volume overload metabolic acidosi uremia most life threatening = hyperkalemia

causes of intrarenal AKI

nephrotoxins, ischemic injury, inflammatory insult -> ATN (acute tubular necrosis)

What kind of AKI would glomerulonephritis cause? (prerenal, renal, or postrenal)

renal

Acute tubular necrosis (ATN)

the most common type of intrinsic AKI, in which there is damage to the kidney tubules causes: - Prolonged renal ischemia - Exposure to nephrotoxic drugs - Acute renal disease

peritoneal dialysis

uses the patient's peritoneal membrane as the semipermeable membrane to exchange fluid and solutes

what are nursing interventions for AKI?

- Maintain fluid balance (strict I & O) - Monitor/manage electrolytes (potassium, sodium, calcium) - Monitor/manage hypertension - Prevent infection - Nutrition - Promote growth & development - Educate & advocate - Provide emotional support - Dialysis may be indicated

The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure? Dehydration Hyperkalemia Crackles Hypertension

Dehydration Explanation: The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.

What is used to decrease potassium level seen in acute renal failure? Sodium polystyrene sulfonate Sorbitol IV dextrose 50% Calcium supplements

Sodium polystyrene sulfonate Explanation: The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.

A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? Keep the AV fistula site dry. Keep the AV fistula wrapped in gauze. Take the client's blood pressure in the left arm. Assess the AV fistula for a bruit and thrill.

Assess the AV fistula for a bruit and thrill. Explanation: The nurse needs to assess the AV fistula for a bruit and thrill because if these findings aren't present, the fistula isn't functioning. The AV fistula may get wet when the client isn't being dialyzed. Immediately after a dialysis treatment, the access site should be covered with adhesive bandages, not gauze. Blood pressure readings or venipunctures shouldn't be taken in the arm with the AV fistula.

acute kidney injury

formerly acute renal failure the rapid loss of renal function due to damage to the kidneys. It results in the retention of urea and other nitrogenous waste products and the dysregulation of extracellular volume and electrolytes

what are the criteria used for RIFLE classification system?

1. GFR criteria: GFR and increased serum creatinine 2. urinary output

The nurse is planning client teaching for a client with end-stage kidney disease who is scheduled for the creation of a fistula. The nurse should teach the client what information about the fistula? "A vein and an artery in your arm will be attached surgically." "The arm should be immobilized for 4 to 6 days." "One needle will be inserted into the fistula for each dialysis treatment." "The fistula can be used 5 to 7 days after the surgery for dialysis treatment."

"A vein and an artery in your arm will be attached surgically." Explanation: The fistula joins an artery and a vein, either side-to-side or end-to-end. This access will need several weeks to "mature" before it can be used. The client is encouraged to perform exercises to increase the size of the affected vessels (e.g., squeezing a rubber ball for forearm fistulas). Two needles will be inserted into the fistula for each dialysis treatment.

A client with end-stage renal disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? Inform the health care provider and assess the client for signs of infection. Flush the peritoneal catheter with normal saline. Remove the catheter promptly and have the catheter tip cultured. Administer a bolus of IV normal saline as prescribed.

Inform the health care provider and assess the client for signs of infection. Explanation: Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the physician would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? Encourage oral fluids. Administer furosemide (Lasix) 20 mg IV Start hemodialysis after a temporary access is obtained. Start IV fluids with a normal saline solution bolus followed by a maintenance dose.

Start IV fluids with a normal saline solution bolus followed by a maintenance dose. Explanation: The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.

What kind of AKI would dehydration cause? (prerenal, renal, or postrenal)

dehydration --> reduced intravascular volume = prerenal

hemodialysis

the process by which waste products are filtered directly from the patient's blood circulates the patient blood through an artificial kidney (dialyzer) to remove waste products and excess fluid