Care of Acute Kidney Injury and Chronic Kidney Disease

Sodium polystyrene sulfonate Sodium polystyrene sulfonate is administered for the treatment of hyperkalemia. It works by eliminating excessive potassium via bowel evacuation. It should be avoided in a patient with decreased gastrointestinal motility because it could lead to bowel obstruction and/or bowel necrosis.

"Less protein will be lost using HD than PD." Lower protein loss is a benefit of HD. HD can be more specific depending on the type of dialysis membrane that is selected. "HD is more efficient at removing waste products than PD." HD is more efficient at removing waste products than PD. HD rapidly removes urea, creatinine, and excess potassium.

A patient with late stage chronic kidney disease (CKD) wants to know why active-form vitamin D has been prescribed. How would the nurse explain the use of this drug therapy to the patient?

"The kidney is no longer activating vitamin D, which will prevent calcium from being absorbed." With late stage CKD, the kidney no longer activates vitamin D. This prevents the absorption of calcium in the gut and can lead to mineral and bone disorders.

A patient with CKD, who receives hemodialysis three times weekly, has a urine output of 200 mL for the day. The nurse calculates the recommended daily fluid intake for this patient to be __ mL of fluid.

800 Urine output + 600 mL [insensible loss] = recommended fluid intake; 200 mL + 600 mL = 800 mL of fluid.

Which clinical manifestations or lab values would indicate to the nurse that dialysis (renal replacement therapy) may be required for a patient with acute kidney injury (AKI)? Select all that apply.

BUN >120 mg/dL BUN levels >120 mg/dL require dialysis in the AKI patient. Volume overload Volume overload with compromised cardiac or pulmonary status requires renal replacement therapy. Metabolic acidosis Metabolic acidosis, with serum bicarbonate levels less than 15 mEq/L, requires dialysis. Elevated serum potassium Elevated serum potassium levels may require dialysis to prevent cardiac dysrhythmias.

Which menu items would the nurse remove from the meal tray of a patient with chronic kidney disease who is not currently receiving dialysis? Select all that apply.

Bananas Bananas are a high-potassium food and should be avoided for patients with CKD on dietary restrictions. Further education regarding high-potassium foods is required. Hard boiled eggs Hard boiled eggs are high in protein, and the yolk contains cholesterol; thus they should be avoided for patients with CKD on dietary restrictions. Further education would be necessary to discuss restricting protein and cholesterol.

A patient with chronic kidney disease (CKD) asks the nurse to help him make choices for dinner. The nurse notes that the patient has been ordered a low-protein, low-sodium, low-potassium diet. Which items on the patient's meal tray should the nurse remove to meet the dietary recommendations? Select all that apply.

Beef steak Beef steak should be removed to meet the dietary recommendation of low-protein. Salt substitutes Salt substitutes will conflict with a restricted potassium diet due to the fact that potassium chloride is a main ingredient in salt substitute. Plain baked potato Baked potato would be a good source of carbohydrate calories; however, this is also considered a high potassium food and should be removed.

A patient who will soon begin dialysis requests more information about how dialysis will fit into their life. The patient would like to remain involved with work (full-time) and family activities, including day trips. Which statement by the nurse is most appropriate?

Continuous ambulatory peritoneal dialysis (CAPD) is the best option for you." CAPD is typically performed 4 times a day and takes about 30-45 minutes to complete but activities can continue while dialyzing. This would still allow the patient to continue with work and family activities.

Which interventions does the nurse know are available to manage hyperkalemia in a patient with acute kidney injury (AKI)? Select all that apply.

Dialysis Dialysis can be used to remove potassium from the body through the processes of diffusion and filtration. Calcium gluconate Calcium gluconate will stabilize the myocardium to prevent cardiac dysrhythmia while the patient has hyperkalemia. Sodium polystyrene sulfonate Sodium polystyrene sulfonate removes potassium from the body by pulling it into the colon for evacuation via bowel movement(s). Insulin and sodium bicarbonate Insulin and sodium bicarbonate serve as temporary treatment for hyperkalemia by promoting a shift of potassium into the cells. Eventually, the potassium will diffuse back into the bloodstream, thus this intervention is not considered to be long-term management.

A 93-year old patient with end-stage renal disease (ESRD) refuses dialysis. The patient's family insists the patient cannot make that decision on their own. The nurse talks with the patient and determines that the patient is mentally stable and does not want aggressive treatment. The patient states they would like a peaceful, dignified death. Clinically, the patient has continued to lose weight despite the worsening of peripheral edema. Which action should the nurse take to support the patient's request?

Explain to the family that the patient is competent. Treatment would be burdensome to the patient and is not what the patient desires. The patient demonstrates competency. Treatment could even be considered harmful if it does not allow her to die with dignity as she has requested.

A patient undergoing hemodialysis will likely have an arteriovenous fistula or graft. Which specific safety precautions would the nurse take to care for these patients, in regards to their dialysis access?

Interventions to prevent clotting of the vascular access The AV fistula or graft forms a large vascular access point with high volume, turbulent blood flow. Precautions to prevent clotting are essential. Meticulous aseptic technique to prevent infection of vascular access Prevention of infection is always of utmost importance when a patient has direct vascular access. Peripheral venous access and venipuncture should be in the contralateral extremity For vein preservation and hemodialysis fistula/graft protection, IV line placement and venipuncture should be done on the opposite extremity. Blood pressure measurements should be in the contralateral extremity Blood pressure should not be taken on the extremity that has the AV fistula/graft. This is to prevent significant increases in pressure at the fistula/graft area.

What is the recommendation regarding the use of diuretics for a patient with acute kidney injury (AKI) during the oliguric phase?

Not recommended, may be harmful Diuretic therapy is not recommended during the oliguric phase and can cause additional harm.

Which nutritional food group limitations would the nurse recommend to a patient with CKD and renal osteodystrophy in order to help manage the diagnosis?

Protein Foods that are rich in protein are often high in phosphorus and should be avoided. Phosphorus exchanges with calcium in the blood, increasing calcium excretion. Phosphorus Foods high in phosphorus include nuts, dried beans, bran, and garlic. Phosphorus exchanges with calcium in the blood, increasing calcium excretion. These foods should be avoided to prevent the worsening of the osteodystrophy.

Some patients may feel weak and have low blood pressure immediately following hemodialysis (HD). How would the nurse explain the mechanism that caused these symptoms to the patient?

Rapid fluid shifts can occur during HD as fluid is removed from the body. The rapid shift in fluid volume can cause hypotension, which leads to feelings of weakness and dizziness.

Which dietary interventions would the nurse institute to prevent hypertension and edema in a patient with acute kidney injury (AKI)? Select all that apply.

Restrict foods that are high in sodium Sodium can cause fluid retention, which leads to hypertension and edema. Restrict foods that are high in potassium Potassium should be restricted in AKI in order to prevent volume expansion and hypertension. Potassium restriction will also prevent dysrhythmias.

Which treatment would be avoided for a patient with decreased gastrointestinal motility who has CKD?

Sodium polystyrene sulfonate Sodium polystyrene sulfonate is administered for the treatment of hyperkalemia. It works by eliminating excessive potassium via bowel evacuation. It should be avoided in a patient with decreased gastrointestinal motility because it could lead to bowel obstruction and/or bowel necrosis.

Patients with end-stage renal disease (ESRD) receive maintenance dialysis. The nurse tells a patient with ESRD that dialysis may no longer be required due to which reason?

The patient will receive a kidney transplant. A patient receiving a kidney transplant would no longer need dialysis after the transplant. A patient with ESRD would not spontaneously have improved kidney function, and age is not a limitation for dialysis. A patient with severe dementia may not be a candidate for renal transplant and would need to remain on dialysis.

Which issues would the nurse take into consideration when discussing dialysis versus kidney transplantation as management strategies for a patient with end-stage renal disease?

The physical ability to receive a kidney transplant. The patient must be physically able to receive the transplant. Patients with comorbidities may not survive the surgery. The patient's mental competency to make the decision. The patient needs to be mentally stable and competent to make the decision to continue dialysis and not pursue transplant. The reasoning behind the patient's decision regarding their treatment. The nurse should consider why the patient has chosen to manage their disease in a particular way and advocate for the patient, while providing support and education.

A patient with chronic kidney disease (CKD) asks the nurse why their diet is restricted in protein. Which explanation would the nurse provide to better help the patient understand their diet?

To limit catabolic production of nitrogenous waste Protein restriction is necessary to prevent the accumulation of protein waste products. Nausea, anorexia, and vomiting can result from increased waste products in the blood.

Which statement is the rationale for discontinuing metformin in a patient with chronic kidney disease (CKD) and diabetes who has worsening kidney function?

To prevent drug accumulation and possible toxicity Decreased kidney function results in decreased elimination. Therefore, accumulation of drugs in the bloodstream (such as metformin) and the potential for drug toxicity increases.

The nurse instructs a patient with CKD and mineral bone disorder to take which medications with food in order to maximize function?

Vitamin D Vitamin D should be taken with food containing fat. This fat-soluble vitamin is best absorbed with the fat contained in the diet. Calcimimetics Calcimimetics can be taken with food or shortly after a meal. This medication helps with secondary hyperparathyroidism caused by the low blood calcium levels. Phosphate binders Phosphate binders should be taken with food, because phosphate binding occurs in the bowel. The phosphate is then eliminated with the stool.