AKI - NCIV Exam 3
A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? A. Hemodialysis B. Peritoneal dialysis C. Continuous venovenous hemodialysis (CVVHD) D. Plasmapheresis
C CVVHD facilitates the removal of uremic toxins and fluid. The hemodynamic effects of CVVHD are usually mild in comparison to hemodialysis, so CVVHD is best tolerated by an unstable client. Peritoneal dialysis is not the best choice, as the client may have sustained abdominal injuries during the accident and catheter placement would be risky. Plasmapheresis does not achieve fluid removal and electrolyte balance.
Intra-renal
-Damage to renal parenchyma and nephrons (something inside the kidneys that are causing the damage) -Happening to kidneys themselves
How does shock (in general) cause pre-renal AKI
-Decreased BP or perfusion -Hypovolemic shock (decreased volume that decreases the perfusion to the kidneys) -Septic shock (decreased amount of volume; decreased volume to the kidneys -Cardiogenic shock (weak pump decreasing perfusion) -Neurogenic shock (body doesn't have compensatory mechanisms, so decreased CO
How do hemodynamics cause pre-renal AKI
-Decreased CO which will decrease perfusion to kidneys -Decrease CVP = decreasing volume -Vasoactive drugs (might constrict too much; goal is to get better perfusion to main organs à brain, heart, lungs; body doesn't give priority to kidneys, so squeeze vessels to our kidneys as much as possible and might squeeze too much that blood can't get through and decrease perfusion to kidneys)
How do dysrhythmias cause pre-renal AKI
-Decreases or stops CO -If don't have CO, don't have blood flow/perfusion to kidneys
What happens to solutes and water if the kidneys aren't working
-Electrolytes like sodium, potassium, and magnesium will not be within normal limits -Kidneys don't excrete out water or urine; imbalance of volume
What happens in CKI if the kidneys aren't working
-Endocrine dysfunction; not able to regulate BP -Decrease in RBC production/erythropoietin -Calcium isn't able to metabolize; as GFR decreases, phosphorus increases, and as phosphorus increases, calcium decreases
Labs and diagnostic tests for intra-renal AKI
-GFR -Electrolytes -UA -Creatinine -BUN -Renal ultrasound -Renal angiogram -ABG
Labs and diagnostic tests for pre-renal AKI
-GFR -Electrolytes -UA -Creatinine -BUN -Renal ultrasound (rules out obstruction or something else that's going on) -ABG
Labs and diagnostics tests for post-renal AKI
-Grossly elevated creatinine (like high, like 11) -CT kidney -Cystoscopy -MRI -Renal ultrasound -Renal biopsy -IVP (intravenous pyelogram)
What are the two types of dialysis
-Hemodialysis (intermittent) -CRRT
Causes of pre-renal AKI
-Hemodynamics -Dysrhythmias -Burns -Cardiovascular alterations -Trauma -Hypovolemia -Blood loss/hemorrhage -Cardiovascular failure (pump failure/decreased contractility) -Shock (in general) -Sepsis (increased vessel size) -Dehydration -Third-spacing -Medications
What is the assessment for CRRT
-Hemodynamics -Hourly I/0 -Frequent assessment of electrolytes *-Hemocatheter only*
What is the assessment for intermittent hemodialysis
-Hemodynamics -Vascular access (fistula, graft, temporary, or permanent) -Medications
Interventions for risk for excess fluid volume for AKI
-I/O, daily weight, lung sounds, edema -Monitor for hypertension, pulmonary edema -Restrict fluids as ordered -Administer diuretics *(if patient has some kidney function because diuretics such as furosemide work in the kidney; if kidney isn't working/necrotic, med isn't going to work)* -Dialysis *(if patient does not have enough kidney function)*
How does sepsis/septic shock cause intra-renal AKI
-If it goes to DIC -Large bacteria toxins in bloodstream that clog up kidneys -Meds used to treat sepsis --> antibiotics that are nephrotoxic
What is acute renal failure
-In an acute condition, symptoms appear and change or worsen rapidly, as in a heart attack
S/S of AKI
-Increase in potassium, sodium, and phosphorus -Decrease in calcium -Metabolic acidosis -Increased preload -Decrease in production of RBCs (erythropoiesis) -Decreased GFR -Increased creatinine (azotemia) -Increased BUN -Oliguria (<500mL/day) -Non-oliguria (>500mL/day) -Anuria (<50mL/day - rare)
Interventions for risk for infection for AKI
-Increase risk with hemocath -Check s/s of infections (temp, site care, PD fluid) -Good hand washing -Teach client site care of dialysis site -Monitor labs (WBC, procalcitonin)
Failure
-Increased creatinine -UOP < 0.3mL/kg/hr x 24 hr or anuria x hr
Injury
-Increased creatinine -UOP < 0.5mL/kg/hr x 12 hr
Risk
-Increased creatinine -UOP < 0.5mL/kg/hr x 6 hr
Nursing diagnoses for AKI
-Ineffective tissue perfusion -Risk for excess fluid volume *-Imbalanced nutrition* -Risk for infection -Deficient knowledge
What causes AKI
-Ischemia -Nephrotoxicity -Previous lecture topics
What is acute tubular necrosis (ATN) caused by
-Ischemia (any unresolved pre-renal issues) -Nephrotoxins (IV contrast, NSAIDs, Aminoglycosides) -Kidney transplant rejection
What ureteral obstruction causes post-renal AKI
-Kidney stones -Tumor: in the kidney or post kidney -Blood clots
What happens to acid/base balance if kidneys aren't working
-Kidneys don't produce bicarb -Causes metabolic acidosis
How do cardiovascular alterations cause intra-renal AKI
-MI --> will go to cath lab -Dye in cath lab is nephrotoxic and can cause intra-renal issues
What bladder problems cause post-renal AKI
-Neurogenic Bladder (SCI) -Clots -Tumor -Bladder Stones
*What does creatinine tell us?*
*-Creatinine is a waste product* *-Tells us kidney function and the ability of the kidneys to remove waste products*
*What is the #1 lab associated with kidney function?*
*Creatinine*
*What is the #1 treatment for AKI*
*Prevention*
How often is intermittent hemodialysis done?
-3-5 hours -3x/week
How do burns cause intra-renal AKI
-A lot of tissue damage depending on severity of burn -Causes release of CK leading to rhabdomyolysis and clogging up the inside of the kidneys
What are the types of access for hemodialysis
-Permanent (fistula, graft) -Temporary (hemocath/permacath)
Loss
-Persistent acute renal failure -Complete loss of kidney function > 4 weeks
What are the indications for intermittent hemodialysis
-Rapid removal of excess water and waste products -Hyperkalemia -Drug overdose
What are the indications for CRRT
-Remove excess waste products when hemodynamically unstable -Fluid volume overload -Septic Shock (clear out toxins in blood)
What type of renal failure is intermittent hemodialysis used for?
-Acute and chronic -Can use permanent (fistulas, grafts) or temporary (hemocath/permacath) because it's hooked up for 3-5 hours and then discontinued
Interventions for ieffective tissue perfusion for AKI
-Acute more than chronic -Monitor medications: ACE inhibitors, angiotensin II -Avoid nephrotoxic drugs -Monitor I/O, weight, respiratory status, BUN, creatinine -Treat electrolyte imbalance
What causes intra-renal AKI
-Acute tubular necrosis (ATN) -Acute Glomerulonephritis -Vascular Disease -DIC -Radiation -Rhabdomyolysis -Sepsis/septic shock -Trauma -Burns -Cardiovascular alterations -MODS
Post-renal
-Any condition that affects/prevents urine excretion -Anything that is obstructing the urine from coming out (kidneys to bladder or bladder on out)
How does trauma cause pre-renal AKI
-Anything that affects circulation/decrease blood flow -Pelvic, spleen, liver injuries
Pre-renal
-Anything that causes a decreased blood flow to the kidneys -Anything that's affecting above the kidneys/anything that will affect the pumping ability of heart or blood flow coming out of the heart
How do cardiovascular alterations cause pre-renal AKI
-Anything that's going to decrease pump (MI and have lower EF will decrease CO) -Meds to improve HR (ACE, ARS = can decrease GFR and lead to pre-renal issues -NSAIDs can decrease GFR and can cause pre-renal issues
What urethral obstruction causes post-renal AKI
-BPH or Prostate Cancer -Stones or strictures -Obstructed indwelling catheter
What are complications of CRRT
-Bleeding -Hypotension
What are the complications of intermittent hemodialysis
-Bleeding -Hypotension -Dialysis disequilibrium (mental status changes due to fluid and electrolyte shift)
RIFLE
-Risk -Injury -Failure -Loss -ESKD
What is the maintenance phase of AKI
-Significant decrease in GFR -Oliguria -S/S of renal failure present -Will lead to CKD if not treated
Interventions for deficient knowledge for AKI
-Teach client about disease process and management -Teach about infection control -Fear/anxiety -Depression -Spiritual needs
What is the initiation phase of AKI
-Time between kidney injury and decrease in kidney function -Few s/s -Prevention -Just concerned
Treatment of intra-renal AKI
-Treat the cause -Hydrate to protect the kidneys so don't have worsening damage -Treat infection -Compensate until kidney function restored (hemodialysis vs CRRT)
Treatment of post-renal AKI
-Treat the cause -TURP vs OR -Lithotripsy for stones -Hemodialysis until the cause is fixed
What is the recovery phase of AKI
-Tubular cell repair -Gradual return of normal GFR -Kidneys will start to auto diuresis
What causes post-renal AKI
-Ureteral obstruction -Bladder problems -Urethral obstruction
What medications cause pre-renal AKI
-Vasoactive drugs at HIGH DOSES --> norepinephrine, dopamine, epinephrine, vasopressin (anything that will constrict blood vessels) -NSAIDs -Nephrotoxic antibiotics (aminoglycosides) --> gentamicin, vancomycin -ACE inhibitors
How does trauma cause intra-renal AKI
-When have muscle breakdown, leads to an increase in CK which can lead to rhabdomyolysis -All of the big proteins from the muscle will clog up kidneys
The nurse is caring for a patient that has developed oliguria. Oliguria is defined as urine output less than ___________mL/kg/hr
0.5
What are the 3 life-sustaining tasks the kidneys do
1. Balance solutes and water 2. Excrete wastes and conserve nutrients 3. Regulate acid/base balance
What are the three phases of AKI
1. Initiation 2. Maintenance 3. Recovery
How often is CRRT done?
24/7
The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take? A. Hold the medication and clarify with provider B. Check with the dialysis nurse about the medication C. Ask if the client wants to take the medications, based on past response to dialysis D. Administer the medications as ordered
A
A client is admitted to the hospital with a prerenal disorder, a non-urologic condition that disrupts renal blood flow to the nephrons, affecting their filtering ability. One cause of prerenal acute kidney injury is: A. Anaphylaxis B. Polycystic kidney disease C. Myoglobinuria secondary to burns D. Ureteral stricture
A Anaphylaxis changes the vessel size, decreasing perfusion Myoglobinuria is muscle breakdown in urine
A client is admitted to the hospital with a prerenal disorder, a nonurologic condition that disrupts renal blood flow to the nephrons, affecting their filtering ability. One cause of prerenal acute kidney injury is: A. Anaphylaxis B. Myoglobinuria secondary to burns C. Polycystic disease D. Ureteral stricture
A Anaphylaxis is a cause of prerenal acute renal failure. Myoglobinuria secondary to burns is a cause of intrarenal acute renal failure. Polycystic disease is a cause of intrarenal acute renal failure. Ureteral stricture is a cause of postrenal acute renal failure.
The laboratory results for a patient with renal failure, accompanied by decreased glomerular filtration, would be evaluated frequently. Which of the following is the most sensitive indicator of renal function? A. Serum creatinine of 1.5 mg/dL B. BUN of 20 mg/dLb C. Creatinine clearance of 90 mL/min D. Urinary protein level of 150 mg/24h.
A As glomerular filtration decreases, the serum creatinine and BUN levels increase and the creatinine clearance decreases. Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body. The BUN is affected not only by renal disease but also by protein intake in the diet, tissue catabolism, fluid intake, parenteral nutrition, and medications such as corticosteroids.
The nurse is caring for a client whose acute kidney injury has prerenal cause. What most likely caused this client's health problem? A. Heart failure B. Glomerulonephritis C. Ureterolithiasis D .Aminoglycoside toxicity
A By causing inadequate renal perfusion, heart failure can lead to prerenal failure. Glomerulonephritis and aminoglycoside toxicity are renal causes, and ureterolithiasis is a postrenal cause.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? A. Encouraging coughing and deep breathing B. Promoting carbohydrate intake C. Limiting fluid intake D. Providing pain-relief measures
C During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and IV fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.
The nurse is caring for acutely ill client. What assessment finding should prompt the nurse to inform the physician that the client may be exhibiting signs of acute kidney injury (AKI)? A. The client reports an inability to initiate voiding. B. The client's urine is cloudy with a foul odor. C. The client's average urine output has been 10 mL/hr for several hours. D. The client complains of acute flank pain.
C Oliguria (<500 mL/day of urine) is the most common clinical situation seen in AKI. Flank pain and inability to initiate voiding are not characteristic of AKI. Cloudy, foul-smelling urine is suggestive of a urinary tract infection.
A patient undergoing a CT scan with contrast has a baseline creatinine level of 3 mg/dL, identifying this patient as at a high risk for developing kidney failure. What is the most effective intervention to reduce the risk of developing radiocontrast-induced nephropathy (CIN)? A. Performing the test without contrast B. Administering Garamycin (gentamicin) prophylactically C. Hydrating with saline intravenously before the test D. Administering sodium bicarbonate after the procedure
C Radiocontrast-induced nephropathy (CIN) is a major cause of hospital-acquired AKI. This is a potentially preventable condition. Baseline levels of creatinine greater than 2 mg/dL identify patients at high risk. Limiting the patient's exposure to contrast agents and nephrotoxic medications will reduce the risk of CIN (Murphy & Byrne, 2010; Rank, 2013). Administration of N-acetylcysteine and sodium bicarbonate before and during procedures reduces risk, but prehydration with saline is considered the most effective method to prevent CIN
A nurse is caring for a client who is in the diuresis phase of acute kidney injury. The nurse should closely monitor the client for what complication during this phase? A. Hypokalemia B. Hypocalcemia C. Dehydration D. Acute flank pain
C The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. Excessive losses of potassium and calcium are not typical during this phase, and diuresis does not normally result in pain.
An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The client has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the client is aware that what precipitating factors in this client may contribute to AKI? Select all that apply. A. Anxiety B. Low BMI C. Age-related physiologic changes D. Chronic systemic disease E. NPO status
C, D Changes in kidney function with normal aging increase the susceptibility of elderly clients to kidney dysfunction and kidney injury. In addition, the presence of chronic, systemic diseases increases the risk of AKI. Low BMI and anxiety are not risk factors for acute renal disease. NPO status is not a risk, provided adequate parenteral hydration is given.
ESKD
Complete loss of kidney function > 3 months
A client diagnosed with acute kidney injury (AKI) has developed congestive heart failure. The client has received 40 mg of intravenous push (IVP) Lasix and 2 hours later, the nurse notes that there are 50 mL of urine in the Foley catheter bag. The client's vital signs are stable. Which health care order should the nurse anticipate? A. Lasix 80 mg IVP B. Normal saline bolus of 500 mL C. Chest x-ray D. Mannitol 12.5 g IVP
A Diuretic agents are often used to control fluid volume in clients with acute kidney injury (AKI). The client's urine output indicates an inadequate response to the initial dosage of Lasix and the nurse should anticipate administering Lasix 80 mg IVP. Often in this situation, the initial dosage of Lasix is doubled. The client is experiencing fluid overload, thus, a 500-mL bolus of normal saline bolus would be contraindicated. There is no need to complete a chest x-ray. Mannitol is widely used in the management of cerebral edema and increased intracranial pressure from multiple causes.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? A. Limiting fluid intake B. Promoting carbohydrate intake C. Encouraging coughing and deep breathing D. Providing pain-relief measures
A Don't want them to be fluid overloaded
Since Mr. Murray has hyperkalemia, the nurse will monitor closely for potential A. Cardiac arrhythmias. B. Nonspecific seizures. C. Aspiration emesis. D. Respiratory suppression.
A Hyperkalemia can cause progressive electrocardiographic abnormalities such as peaked T waves, flattening or absence of P waves, or widening QRS complexes.
During his hospital stay, Mr. Day is started on captopril (Capoten) 12.5 mg 3 times a day. What class of antihypertensive medication is this drug? A. Angiotensin-converting enzyme (ACE) inhibitor. B. Calcium channel blocker. C. Primary vasodilating agent. D.Beta adrenergic blocker.
A Knowing that captopril is an ACE inhibitor prescribed for his hypertension, the nurse will assess the patient's blood pressure to monitor its efficacy.
Currently the staff is following routine standard precautions with Ms. Howe. However, during the assessment, Ms. Howe complains of having uncontrolled diarrhea. Ms. Howe's plan of care will have the A. Dialysis treatment set up in a separate room or area. B. Staff use the automated blood pressure cuff. C. Patient wear gloves while in the unit. D. Equipment cleansed with 1:1000 diluted bleach.
A Per CDC guidelines, separating Ms. Howe from the other patients as much as possible will help prevent the transmission of infection.
A client develops acute renal failure (ARF) after receiving IV therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 mL, the nurse suspects that the client is at risk for A. Cardiac Arrhythmia B. Paresthesia C. Dehydration D. Pruritus
A Potassium could be elevated because kidneys aren't doing their job
Acute dialysis is indicated during which situation? A. Impending pulmonary edema B. Dehydration C. Metabolic alkalosis D. Hypokalemia
A Quickly remove more fluid. Don't want to remove fluid if dehydrated. Will have metabolic acidosis not alkalosis. Don't want to make potassium lower
Mr. Day has declining kidney function due to hypertension. The nurse knows the physiologic principle causing hypertension is believed to be increased production of A. Renin. B. Antidiuretic hormone (ADH). C. Atrial naturiuretic hormone (ANP). D. Glucocorticoids.
A Renin activates the angiotensin aldosterone system. This in turn causes peripheral vasoconstriction, which increases blood pressure.
Which of the following is the most sensitive indicator of renal function? A. Serum creatinine B. Blood urea nitrogen (BUN) C. Creatinine clearance D. Potassium
A Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body.
The nurse cares for a client after extensive abdominal surgery. The client develops an infection that is treated with IV gentamicin. After 4 days of treatment, the client develops oliguria, and laboratory results indicate azotemia. The client is diagnosed with acute tubular necrosis and transferred to the ICU. The client is hemodynamically stable. Which dialysis method would be most appropriate for the client? A. Hemodialysis B. Peritoneal dialysis C. Continuous arteriovenous hemofiltration (CAVH) D. Continuous venovenous hemofiltration (CVVH)
A The client is hemodynamically stable and hemodialysis would be most appropriate. Hemodialysis is used for clients who are acutely ill and require short-term dialysis for days to weeks until kidney function resumes and for clients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) who require long-term or permanent renal replacement therapy. Peritoneal dialysis (PD) may be the treatment of choice for clients with renal failure who are unable or unwilling to undergo hemodialysis or kidney transplantation. CAVH and CVVH are used for client who are hemodynamically unstable.
A client with acute renal failure progresses through four phases. Which describes the onset phase? A. It is accompanied by reduced blood flow to the nephrons. B. Fluid volume excess develops, which leads to edema, hypertension, and cardiopulmonary complications. C. The excretion of wastes and electrolytes continues to be impaired despite increased water content of the urine. D. Normal glomerular filtration and tubular function are restored.
A The onset phase is accompanied by reduced blood flow to the nephrons. In the oliguric phase, fluid volume excess develops, which leads to edema, hypertension, and cardiopulmonary complications. During the diuretic phase, excretion of wastes and electrolytes continues to be impaired despite increased water content of the urine. During the recovery phase, normal glomerular filtration and tubular function are restored.
What is chronic renal failure
A chronic condition that develops and worsens over an extended period of time, as in atherosclerosis
A client is experiencing a decreasing glomerular filtration. What laboratory values should the nurse expect to follow the change? Select all that apply. A. Serum creatinine increases B. Blood urea nitrogen (BUN) increases C. Creatinine clearance decreases D. Hypokalemia E. Hypophosphatemia
A, B, C As glomerular filtration decreases, the serum creatinine and BUN levels increase; the creatinine clearance decreases. Potassium and phosphate levels should not be affected by decreased glomerular filtration.
The nurse is caring for a client's status after a motor vehicle accident. The client has developed AKI. What are the nurse's roles in caring for this client? Select all that apply. A. Providing emotional support for the family B. Monitoring for complications C. Participating in emergency treatment of fluid and electrolyte imbalances D. Providing nursing care for primary disorder (trauma) E. Directing nutritional interventions
A, B, C, D The nurse has an important role in caring for the client with AKI. The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the client's progress and response to treatment, and provides physical and emotional support. Additionally, the nurse keeps family members informed about the client's condition, helps them understand the treatments, and provides psychological support. Although the development of AKI may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the urinary tract). The nurse does not direct the client's nutritional status; the dietician and the physician normally collaborate on directing the client's nutritional status
Patient education regarding a fistulae or graft includes which of the following? Select all that apply. A. Check daily for thrill and bruit. B. Avoid compression of the site. C. No IV or blood pressure taken on extremity with dialysis access. D. No tight clothing. E. Cleanse site b.i.d.
A, B, C, D The nurse teaches the patient with fistulae or grafts to check daily for a thrill and bruit. Further teaching includes avoiding compression of the site; not permitting blood to be drawn, an IV to be inserted, or blood pressure to be taken on the extremity with the dialysis access; not to wear tight clothing, carry bags or pocketbooks on that side, and not lie on or sleep on the area. The site is not cleansed unless it is being accessed for hemodialysis.
Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. A. Hyperkalemia B. Metabolic alkalosis C. Anemia D. Hyperalbuminemia E. Hypocalcemia
A, C, E Hyperkalemia is due to decreased potassium excretion and excessive potassium intake. Metabolic acidosis results from decreased acid secretion by the kidney. A damaged glomerular membrane causes excess protein loss.
What type of renal failure is CRRT used for?
Alternative for AKI or acute on chronic
Acute dialysis is indicated during which situation? A. Dehydration B. Impending pulmonary edema C. Metabolic alkalosis D. Hypokalemia
B Acute dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary edema, or increasing acidosis.
The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take? A. Administer the medications as ordered. B. Hold the medications until after dialysis. C. Check with the dialysis nurse about the medications. D. Ask if the client wants to take the medications.
B Antihypertensive therapy, often part of the regimen of clients on dialysis, is one example when communication, education, and evaluation can make a difference in client outcomes. The client must know when—and when not—to take the medication. For example, if an antihypertensive agent is taken on a dialysis day, hypotension may occur during dialysis, causing dangerously low blood pressure. Many medications that are taken once daily can be held until after dialysis treatment.
The diagnosis of acute tubular necrosis (ATN), a type of ischemic intrarenal acute kidney injury, has been discussed with Ms. Howe and her family. ATN is usually associated with A. Oliguria and concentrated urine. B. Oliguria and inability to concentrate urine. C. Nonoliguria and sodium retention. D. Nonoliguria and sodium wasting.
B Is usually associated with oliguria because of the extensive nephron injury.
A client is scheduled for a CT scan of the abdomen with contrast. The client has a baseline creatinine level of 2.3 mg/dL (203 µmol/L). In preparing this client for the procedure, the nurse anticipates what orders? A. Monitor the client's electrolyte values every hour before the procedure. B. Preprocedure hydration and administration of acetylcysteine C. Hemodialysis immediately prior to the CT scan D. Obtain a creatinine clearance by collecting a 24-hour urine specimen.
B Radiocontrast-induced nephropathy is a major cause of hospital-acquired acute kidney injury. Baseline levels of creatinine greater than 2 mg/dL (177 µmol/L) identify the client as being at high risk. Preprocedure hydration and prescription of acetylcysteine (Mucomyst) the day prior to the test is effective in prevention. The nurse would not monitor the client's electrolytes every hour preprocedure. Nothing in the scenario indicates the need for hemodialysis. A creatinine clearance is not necessary prior to a CT scan with contrast.
The nurse monitors the client for potential complications during dialysis but recognizes NOT to monitor for A. Muscle cramping. B. Hypertension. C. Dysrhythmias. D. Air embolism.
B The nurse should monitor for hypotension, not hypertension, during the treatment related to the removal of fluid. Muscle cramping may occur late in dialysis as fluid and electrolytes rapidly leave the extracellular space. Dysrhythmias may result from electrolyte and pH changes or removal of antiarrhythmic medications. Air embolism is rare, but could occur if air enters the vascular system.
The nurse cares for a client with acute kidney injury (AKI). The client is experiencing an increase in the serum concentration of urea and creatinine. The nurse determines the client is experiencing which phase of AKI? A. Initiation B. Oliguria C. Diuresis D. Recovery
B The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The initiation periods begins with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.
Which period of acute renal failure is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys? A. Initiation B. Oliguria C. Diuresis D. Recovery
B The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys, such as urea and creatinine. The initiation periods begins with the initial insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal function and may take 6 to 12 months.
Which phase of acute renal failure signals that glomerular filtration has started to recover? A. Oliguric B. Diuretic C. Initiation D. Recovery
B The oliguric period is accompanied by an increase in the serum concentration of wastes such as urea, creatinine, organic acids, and the electrolytes potassium, phosphorous, and magnesium. The initiation period begins with the initial insult and ends when cellular injury and oliguria develops. The diuretic phase is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. The recovery period signals the improvement of renal function and energy level and may take 6 to 12 months.
While Ms. Howe has been receiving dialysis in the acute unit, the staff has been following the Centers for Disease Control and Prevention (CDC) guidelines. These guidelines include A. Changing her dialysis catheter and fistula dressings at the same time. B. Wearing gloves when caring for the patient OR touching the patient's equipment. C. Using a mask and face shield to avoid airborne VRE contamination. D. Performing all tasks before washing their hands.
B Wearing gloves is an important part of the CDC guidelines. The nurse should also remember to sanitize hands after removing gloves and before moving to the next patient.
What lab value doesn't also indicate kidney issue or damage
BUN
A client develops acute renal failure (ARF) after receiving IV therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 mL, the nurse suspects that the client is at risk for: A. Paresthesia. B. Dehydration. C. Cardiac arrhythmia. D. Pruritus.
C As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In the client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia.
A client requires hemodialysis. Which type of drug should be withheld before this procedure? A. Phosphate binders B. Insulin C. Antibiotics D. Cardiac glycosides
D Cardiac glycosides such as digoxin (Lanoxin) should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digoxin toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.
A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure? A. Poor perfusion to the kidneys B. Damage to cells in the adrenal cortex C. Obstruction of the urinary collecting system D. Nephrotoxic injury secondary to use of contrast media
D Intrinsic renal failure results from damage to the kidney, such as from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or bacterial toxins. Poor perfusion to the kidneys may result in prerenal failure. Damage to the epithelial cells of the renal tubules results from nephrotoxic injury, not damage to the adrenal cortex. Obstruction of the urinary collecting system may cause postrenal failure
Discharge teaching for a patient on Lopressor would include discussion of which of the following side effects? A. Fatigue. B. Slow heartbeat. C. Cold hands and feet. D. All of the above
D Knowing that Lopressor is a beta blocker, the nurse will educate patients to monitor their pulse rate as well as BP and to avoid getting up too fast from a lying or sitting position to avoid the risk of falling.
A patient has been diagnosed with postrenal failure. The nurse reviews the patient's electronic health record and notes a possible cause. Which of the following is the possible cause? A. Acute pyelonephritis B. Osmotic dieresis. C. Dysrhythmias D. Renal calculi
D Postrenal ARF is the result of an obstruction that develops anywhere from the collecting ducts of the kidney to the urethra. This results from ureteral blockage, such as from bilateral renal calculi or benign prostatic hypertrophy (BPH).
Which of the following would a nurse classify as a prerenal cause of acute renal failure? A. Polycystic disease B. Ureteral stricture C. Prostatic hypertrophy D. Septic shock
D Prerenal causes of acute renal failure include hypovolemic shock, cardiogenic shock secondary to congestive heart failure, septic shock, anaphylaxis, dehydration, renal artery thrombosis or stenosis, cardiac arrest, and lethal dysrhythmias. Ureteral stricture and prostatic hypertrophy would be classified as postrenal causes. Polycystic disease is classified as an intrarenal cause of acute renal failure.
Approximately 20-60% of hospitalized patients who develop AKI require dialysis. Scoring systems are used to predict patient outcomes. The system that classifies patients based on their glomerular filtration rate (GFR) and/or urine output in mL/kg/hr is the A. APACHE II. B. SOFA. C. SHARF. D. RIFLE.
D Risk, Injury, Failure, Loss, and End stage kidney failure. Patients are classified based on estimated GFR ranges and/or urine output. May be helpful in deciding when to initiate KRT.
Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure? A. Urinary retention B. Activity intolerance C. Disturbed body image D. Fluid volume excess
D The oliguric phase is characterized by fluid retention.
How does MODS cause intra-renal AKI
DIC (micro clots that will go to kidneys and can clog them up)
What must you use with CRRT
Dialysis catheter
Treatment for chronic renal failure
Dietary Restrictions: -Control fluids -Decrease PO4, Na, K -Decrease protein -Increase Calcium -Hemodialysis -Peritoneal Dialysis Kidney Transplant: -Living donor -Living not related donor -Cadaver donor -No treatment
What is an expected side effect of hemodialysis
Fatigue
What is NOT an option with CRRT
Fistula or graft
What is the #2 treatment for AKI
Hemodialysis (intermittent or CRRT)
Where is CRRT done?
ICU ONLY
How do burns cause pre-renal AKI
Increased permeability that happens with loss of skin decreasing overall circulating volume
*Interventions for imbalanced nutrition for AKI*
Monitor renal diet intake: -Limit fluids, decrease protein, sodium, potassium, & phosphorus (dietary restrictions vary person to person) -Small frequent meals or special tube feeding formula -Give antiemetic's, antacids, famotidine, pantoprazole *Hyperkalemia:* *-Sodium polystyrene sulfonate (kayexalate)* (oral, NG, or enema) -Bicarb + insulin + glucose + calcium chloride (IV) - move potassium from vascular space back into cell, decreasing potassium -Continuous albuterol (short-term but quickly) -Furosemide (Lasix) -Hemodialysis Administer supplements: -Folic acid/iron for anemia -Epogen to stimulate erythropoietin Avoid these meds: -Alka-Seltzer -MOM -ASA -Enema/laxatives -Vitamins -Herbs/supplements
Who must you work with for intermittent hemodialysis
Must work with dialysis center schedule
When is CRRT used?
ONLY when the patient is hemodynamically unstable (low BP, multiple vasoactive drugs)
In what population is AKI common in?
Older adults > 60
What type of dialysis IS NOT an option for AKI
Peritoneal dialysis
What lab value has the greatest impact on hemodynamic stability
Potassium
CKD stages
Renal insufficiency: -Stage 1 and 2 -Have 20-50% renal function Renal failure: -Stage 3 and 4 -Have <20% renal function ESRD: -Stage 5 -Have <5% renal function
Treatment of pre-renal AKI
Restore perfusion: -Replace what is lost -Isotonic IVF (LR, NS), blood, albumin -Dopamine (low dose 0-3 mcg/kg/min; should see increase in UOP, better electrolyte balance, better acid/base balance) Identify and treat the cause: -If septic, treat infection -If GI bleed, stop the bleed Prevent additional damage: -Restore UOP and kidney function -Avoid nephrotoxic meds Compensate until kidney function restored: -Manage electrolytes (pg. 580) -Diuretics -Hemodialysis vs CRRT
What is the management of CRRT
Treatment 24/7 by ICU RN
What is the management for intermittent hemodialysis
Treatment length 3-4 hours with dialysis RN
What happens to wastes and nutrients if the kidneys aren't working
Wastes and creatinine are elevated
Why does AKI need quick reversal?
Will turn to chronic renal failure
