Renal

Acute Tubular Necrosis (ATN)

This is a form of Intrarenal Most common cause -prolonged renal ischemia and nephrotoxic injury Potentially reversible

Initiating Phase (Phase 1)

Begins at the time of insult - continues until s/s become apparent last hours to days Look at GFR & UO

Postrenal

Mechanical obstruction to urine outflow TX: find and correct obstruction Resolve quickly with correction of cause

What nursing measure would be included in the plan of care for a client with acute renal failure? 1) Observe for signs of a secondary infection 2) Provide a high protein, low carbohydrate diet 3) In and out catheterization for residual urine 4) Encourage fluids to 2000 mL in 24 hours

1: Secondary infections are the cause of death in 50-90% of clients with acute renal failure. A low protein diet is most often offered. Catheterizations are avoided. Fluids may be limited if the client is in ARF.

A client in renal failure is to have a serum blood urea nitrogen level determined. What will this diagnostic test measure? 1) Concentration of urine osmolarity and electrolytes 2) Serum level of the end products of protein 3) Ability of kidneys to concentrate urine 4) Levels of C-reactive protein to determine inflammation

2: Urea is an end product of protein metabolism. In renal failure, the kidneys cannot clear all of the urea from the blood, and the creatinine and BUN level will be elevated. The C-reactive protein is a diagnostic test used in assessing clients with inflammatory bowel disease, rheumatoid arthritis, autoimmune diseases, and PID. A specific gravity test of the urine would assess the ability of the kidneys to concentrate urine. The urine osmolarity (concentration of particles in urine) and electrolytes assess fluid balance. The kidneys play an important role in the balance of electrolytes and fluids.

Recovery phase (Phase 4)

Gradually the urine output is more normal and will see removal of metabolic wastes so the kidneys are starting to do a better job with filtration. In 1-2 weeks should be able to see some improvements here in memory and strength.... and in the renal function labs but it's still not back to normal....may take up to 12 months to stabilize the renal function. Outcome is based upon severity of the acute renal failure and any complication the patient developed, and the age of the patient. We know that older people already have a problem with less nephrons and ability to concentrate urine as the body normally ages. Some older people will not recover fully. Labs will show an increasing GFR; the BUN and Creatinine will be decreasing; urine specific gravity will increase, K level will decrease. No N/V or muscle twitching seen.

Acute kidney injury (AKA.. Acute renal failure) Labs

Increased BUN, CR, K and GFR less than or equal to 10

A cllient with chronic renal failure has been prescribed calcium carbonate. What is the rationale for this particular medication? 1) Diminishes incidence of gastric ulcer formation 2) Alleviates constipation 3) Binds with phosphorus to lower concentration 4) Increase tubular reabsorption of sodium

3: Clients with ARF have hyperphosphatemia. Clients are prescribed calcium-based phosphate binders to improve excretion of phosphorus.

A client with acute renal failure develops sever hyperkalemia. What would the nurse anticipate to be used to treat this imbalance? 1) Furosemide (Lasix) 2) Amphojel (aluminum hydroxide) 3) 50% glucose and regular insulin 4) Epoetin (Procrit)

3: Hyperkalemia can develop into an emergency situation (Cardia Arrest). It is important to quickly move the potassium back into the cells by administering 50% glucose and regular insulin, usually in conjunction with some type of base to correct the acidosis, such as sodium bicarbonate or calcium gluconate given IV. Insulin assists in the movement of potassium into the cells and helps to reduce the serum potassium level. Amphojel is used for the treatment of hyperphosphatemia that occurs with ARF. Procrit is used for the treatment of anemia caused by a decrease in erythropoietin production by the kidneys. A diuretic, such as Lasix, may lead to a loss of potassium, but the rate is too slow.

A client with chronic renal failure has an internal venous access site for hemodialysis on her left forearm. What action will the nurse take to protect this access site? 1) Irrigate with heparin and NS q8 hrs 2) Apply warm moist packs to the area after hemodialysis 3) Do not use the left arm to take blood pressure readings. 4) Keep the arm elevated above the level of the heart.

3: Protect the arm with the functioning shunt. No blood pressure readings should be taken from that arm, and there should be no needle sticks. The access is not irrigated with Heparin.

Which of the following statements by the nurse regarding continuous ambulatory peritoneal dialysis (CAPD) would be of highest priority when teaching a patient new to this procedure? a.) "It is essential that you maintain aseptic technique to prevent peritonitis." b.) "You will be allowed a more liberal protein diet once you complete CAPD." c.) "It is important for you to maintain a daily written record of blood pressure and weight." d.) "You will need to continue regular medical and nursing follow-up visits while performing CAPD."

A - Peritonitis is a potentially fatal complication of peritoneal dialysis, and thus it is imperative to teach the patient methods of preventing this from occurring. Although the other teaching statements are accurate, they do not have the potential for mortality as does the peritonitis, thus making that nursing action of highest priority.

Acute Kidney Injury

A clinical syndrome characterized by rapid loss of renal function with progressive azotemia and increasing level of serum creatinine

A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. Which of the following is an expected assessment finding for this patient during this early stage of recovery? a.) Hypokalemia b.) Hyponatremia c.) Large urine output d.) Leukocytosis with cloudy urine output

C - Patients frequently experience diuresis in the hours and days immediately following a kidney transplant. Electrolyte imbalances and signs of infection are unexpected findings that warrant prompt intervention.

Uremia

Condition in which renal function declines to the point that symptoms develop in body systems

Intrarenal

Condition that cause direct damage to renal tissue (nepro toxic drugs longer than one week, Progression of Prerenal phase not fixed, Sever ischemia) Has a long recovery phase due to renal damage 4 phases

When caring for a patient during the oliguric phase of acute kidney injury, which of the following would be an appropriate nursing intervention? a.) Weigh patient three times weekly. b.) Increase dietary sodium and potassium. c.) Provide a low-protein, high-carbohydrate diet. d.) Restrict fluids according to previous daily loss.

D - Patients in the oliguric phase of acute kidney injury will have fluid volume excess with potassium and sodium retention; hence, they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 ml for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times a week.

The nurse preparing to administer a dose of PhosLo to a patient with chronic kidney disease would interpret that this medication should have a beneficial effect on which of the following laboratory values of the patient? a.) Sodium b.) Potassium c.) Magnesium d.) Phosphorus Correct

D - Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with chronic kidney disease.

Prerenal

Due to factors external to the kidneys that reduce renal blood flow (hypovolemia decreased CO) TX: Fluid replacement Resolve quickly with correction of cause

Azotemia

An accumulation of nitrogenous wast products

A patient with a history of end-stage renal disease secondary to diabetes mellitus has presented to the outpatient dialysis unit for his scheduled hemodialysis. Which of the following assessments should the nurse prioritize before, during, and after his treatment? a.) Level of consciousness b.) Blood pressure and fluid balance c.) Temperature, heart rate, and blood pressure d.) Assessment for signs and symptoms of infection

B - Although all of the assessments are relevant to the care of a patient receiving hemodialysis, the nature of procedure indicates a particular need to monitor patients' blood pressure and fluid balance.

Which of the following assessment findings is a consequence of the oliguric phase of acute kidney injury (AKI)? a.) Hypovolemia b.) Hyperkalemia c.) Hypernatremia d.) Thrombocytopenia

B - In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.

Labs

BUN 8-20 CR 0.6 - 1.3 GFR 125 ml/min Phosphorus 2.4 - 4.4 Magnesium 1.5 - 2.5 Kidneys reabsorb Na, H2O Kidneys excrete

Oliguric Phase (Phase 2)

Develop oliguria related to a reduction in the GFR Occurs 1-7 days of the causative event Duration 10-14 days, may last months Longer the oliguric phase, poorer prognosis for complete recovery With this phase of Oliguric will see: U/O <400ml/day; may have casts, RBC, WBC in u/a; proteinuria if problem with glomerular membrane. With less urine output expect to see effects of S/S fluid volume excess- sodium level may drop due to hemodilution; metabolic acidosis-kussmauls respirations in attempt to compensate. Fluid restrictions are calculated for the current day as 600ml of insensible losses + output from previous day. - Pre-renal no damage to renal tissue but there is a decrease in circulating blood volume which causes auto regulatory mechanisms to kick in....-RAAS, aldosterone , vasoconstriction to preserve blood flow to essential tissues. urine specific gravity will be high, urine sodium will be low -because the body conserves sodium to retain water to help preserve the blood flow to the organs. - Intra-renal means kidney damage so the kidneys can't reabsorb anything since they are not working well. Think about less reabsorption and more excretion here. You will see urine specific gravity normal, urine sodium high; tubular, RBC, & WBC cast in urine. Acute tubular necrosis is a type of this so lab will be the same.

Diuretic phase (Phase 3)

Kidneys are recovering their ability to excrete wastes but not to concentrate the urine yet so they still aren't filtering right. The nephrons are still not functioning back to normal yet. Expect to see an increase in Urine output of 1-3 L /day seen and this can last 1-3 weeks. But stop and think about this.... We are losing massive fluid losses of electrolytes and water so we need to monitor for hyponatremia, hypokalemia, and dehydration. Eventually we should see some normalization in these electrolyte levels, Bun and Creatinine levels, and acid-base balance at the end of this phase.

Oliguria

UO less that 400 ml/day