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Module 3 > Acute Kidney Injury&Chronic Kidney Disease > Flashcards

Acute Kidney Injury&Chronic Kidney Disease Flashcards

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1
Q

Fluid & Electrolyte Imbalances:In Kidney Disorders

Inadequate fluid – volume depleted

Excess fluid – fluid overload

Monitor:

The most accurate indicator of fluid loss or gain in patients that are acutely ill is _________

A

I & O
Patient weight daily

weight
1 kg weight gain = 1000 ml (retained fluid)

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2
Q

Acute Kidney Injury (AKI)

It is a rapid loss of renal function r/t damage to the kidneys

Depending on severity and duration a wide range of life-threatening complications can occur:

Goal of care:
Minimize complications
Reduce cause of injury
Prevent long term loss of renal function

Criteria for AKI:

A

Fluid & electrolyte imbalances

Metabolic acidosis

-50% or greater increase in serum creatinine above baseline
-Urine volume may be normal or changes may occur:
Oliguria, anuria, Nonoliguria

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3
Q

1 lab to look at for acute kidney injury-

Nonoliguria- anything above

A

serum creatinine

800 ml/day

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4
Q

AKI Causes:

Causes of AKI that reduce blood flow to the kidney and impair kidney function:

A

Hypovolemia

Hypotension

Reduced cardiac output

Heart failure

Obstruction of kidney or lower urinary tract
–Tumor
–Blood clot
–Kidney stone (not very common causes)

Bilateral obstruction of the renal arteries or veins

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5
Q

AKI Classifications:

A

5-point classification system: RIFLE- Risk, Injury, Failure, Loss ESRD (used to identify kidney injury and improve outcomes for patients)

Severity:
Risk
Injury
Failure

Outcomes:
Loss
ESKD (end stage kidney disease)

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6
Q

RIFLE classification table

Risk

GFR Criteria

Urinary output criteria

A

Increased serum creatinine 1.5 x baseline OR GFR decreased >/= 25%

0.5 mL/kg/hr for 6 hours

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7
Q

I (Injury)

GFR

UO

A

Increased serum creatinine 2x baseline
OR
GFR decreased >/= 50 %

0.5 mL/kg/hr for 12 hours

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8
Q

F (failure)

GFR

UO

A

Increased serum creatinine 3x baseline
OR
GFR decreased >/= 75%
OR
Serum creatinine >/= 354 mmol/L with an acute rise of at least 44 mmol/L

< 0.3 mL/kg/hr for 24 hours
OR
Anuria for 12 hours

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9
Q

L (Loss)

A

Persistent acute kidney injury = complete loss of kidney function > 4 weeks

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10
Q

E (ESKD)

A

ESKD > 3 months

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11
Q

AKI Categories:

A

Pre-renal - before the kidneys - hypoperfusion of kidneys
60-70% of cases
result of impaired blood flow that leads to hypoperfsion
(Sudden and severe drop in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury or illness

Intrea-renal-inside the kidneys (actual damage to the kidney tissue)
-Parenchymal damage to the glomeruli or kidney tubules
-Acute tubular necrosis (most common type)
(Direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply)

Post-renal- obstruction to the kidney
(Sudden obstruction to urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury)

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12
Q

AKI Pre-renal failure causes:

A

Volume depletion
Impaired cardiac efficiency
Vasodilation

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13
Q

AKI Pre-renal failure:

Volume depletion resulting from:

A

Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)

Hemorrhage

Renal losses (diuretic agents, osmotic diuresis)

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14
Q

AKI Pre-renal failure:

Impaired cardiac efficiency resulting from:

A

Cardiogenic shock
Dysrhythmias
Heart failure
Myocardial infarction

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15
Q

AKI Pre-renal failure:

Vasodilation resulting from:

A

Anaphylaxis
Antihypertensive medications or other medications that cause vasodilation
Sepsis

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16
Q

AKI Intra-renal failure causes:

A

Prolonged renal ischemia
Nephrotoxic agents
Infectious processes

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17
Q

AKI Intra-renal failure:

Prolonged renal ischemia resulting from:

A

Hemoglobinuria (transfusion reaction, hemolytic anemia)
Rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns)
Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)

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18
Q

AKI Intra-renal failure:

Nephrotoxic agents such as:

A

Aminoglycoside antibiotics (gentamicin, tobramycin)
Angiotensin-converting enzyme inhibitors (captopril)
Heavy metals (lead, mercury)
Nonsteroidal anti-inflammatory drugs (Aspirin, Ibuprofen)
Radiopaque contrast agents
Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)

KNOW ANTIBIOTICS and NSAIDS!!

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19
Q

AKI Intra-renal failure:

Infectious processes such as:

A

Acute glomerulonephritis
Acute pyelonephritis

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20
Q

Contrast agents- be sure to

A

flush out after imaging- drink lots of fluids

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21
Q

AKI Post-renal failure:

Urinary tract obstruction, including:

A

Benign prostatic hyperplasia
Blood clots
Calculi (stones)
Strictures
Tumors
pregnancy

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22
Q

Phases of AKI:

Four phases

A

Initiation
Oliguria
Diuresis
Recovery

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23
Q

Phases of AKI:

Initiation

A

Begins with initial insult and ends when oliguria develops

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24
Q

Phases of AKI:

Oliguria

A

Accompanied by an increase in urea, creatinine, uric acid, organic acids, and K+ and Mg++

Urine output decreases below 400 mL in 24 hours (or 0.5 mL/kg/hr)

Hyperkalemia develops

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25
Phases of AKI: Diuresis
Gradual INCREASE in urine output…glomerular filtration starts to recover Lab values stabilize and improve UOP may reach normal (or even greater than normal) levels Labs may still be abnormal Medical/Nursing mgmt. still continuing until the recovery phase
26
Phases of AKI: Recovery Improvement of renal function and may take from _____ Labs return to normal (or clients’ baseline level) ____ reduction in GFR may occur; however, is not clinically significant
3-12 months 1-3%
27
AKI: assessment & diagnostics:
Urine changes: Urinary output Urine color, clarity, odor, etc Hematuria Specific gravity decreases (one of the earliest manifestations) Decreased sodium in urine Renal sonogram, CT or MRI to determine abnormalities with anatomy BUN and creatinine increase Hyperkalemia -may lead to dysrhythmias (VTACH) and cardiac arrest I&O (folley catheter may be indicated) Daily weights
28
AKI: assessment & diagnostics: Cont. Progressive metabolic _____ ____ levels increase in blood _____
Progressive metabolic acidosis -r/t inability to eliminate daily acid-type substances produced in body -Buffering fails Decreased serum CO2 and pH levels Phosphate levels increase in blood -decreased calcium levels in blood (decreased absorption in the intestines) Anemia -r/t reduced erythropoietin production -uremic GI lesions, blood loss from GI tract
29
AKI diagnostics labs:
Decrease: Specific gravity (one of the earliest signs Sodium in urine calcium levels in blood decreased serum CO2 and ph progressive metabolic acidosis anemia Increase: BUN creatinine hyperkalemia (may lead to Vtach, or cardiac arrest) phosphate levels in blood
30
AKI: prevention Continually assess renal function (urine output, laboratory values) when appropriate. Monitor ____________ of critically ill clients to detect the onset of kidney disease as early as possible. Pay special attention to ____, ____ and other precursors of sepsis. Prevent and treat ______ promptly _____ can produce progressive kidney damage. Prevent and treat shock promptly with blood and fluid replacement. Take precautions to ensure that the appropriate blood is given to the correct client to avoid severe transfusion reactions, which can precipitate kidney disease.
central venous and arterial pressures and hourly urine output wounds, burns, Infections
31
AKI: prevention cont. Provide adequate hydration to clients at risk for dehydration, including:
Before, during, and after surgery Clients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (e.g., barium enema, IV pyelograms), especially older clients who may have marginal renal reserve Clients with neoplastic disorders or disorders of metabolism (e.g., gout) and those receiving chemotherapy Clients with skeletal muscle injuries (e.g., crush injuries, compartment syndrome) Clients with heat-induced illnesses (e.g., heat stroke, heat exhaustion)
32
AKI: prevention To prevent infections from ascending in the: To prevent ____ effects Treat _____ promptly
urinary tract give meticulous care to clients with indwelling catheters Remove catheters as soon as possible toxic drug closely monitor dosage, duration of use, and blood levels of all medications metabolized or excreted by the kidneys hypotension
33
AKI: Medical management
Eliminating underlying cause: Shock (any type); however, sepsis is most common Maintaining fluid balance -Daily weights -Measuring CVPs -Serum and urine concentrations -Fluid losses -Maintaining BP -Parenteral/oral intake, UOP, gastric drainage, stools, wound drainage, and perspiration are basis for fluid replacement Avoid fluid excesses -Dyspnea, tachycardia, and JVD -Crackles auscultated in lungs -edema -Mannitol, furosemide, or ethacrynic acid may be prescribed for diuresis IV fluids and blood / blood product transfusions -For prerenal causes Dialysis to prevent complications of AKI -Hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema
34
AKI: pharmacologic therapy
Hyperkalemia: -EMERGENCY!!! -Potassium level greater than 5 mEq/L -ECG changes (tall, tented, or peaked T waves) -Irritability, abdominal cramping, diarrhea, paresthesia, and generalized muscle weakness -Generalized muscle weakness, slurred speech, difficulty breathing, and paralysis Treatment: Kayexalate Hemodynamic instability: -Low BP, AMS, and/or dysrhythmia -Treatment: IV Dextrose 50%, insulin, and calcium replacement to shift potassium back into cells (temporary…so, dialysis will still be needed) Renal dosing of medications -Since many meds utilize the kidneys to filter; pharmacy can adjust medications accordingly -Common meds: antibiotics, digoxin, phenytoin, ACE inhibitors, and magnesium-containing agents Sodium bicarbonate: Since client is typically more acidotic, sodium bicarb may be given; however, dialysis may still be needed for long-term effect Phosphate-binding agents: -T-reatment of hyperphosphatemia -Calcium or lanthanum carbonate decrease levels by decreasing absorption from the intestinal tract
35
CKD: Chronic Kidney Disease An umbrella term describing -kidney damage -decrease in the glomerular filtration rate (GFR) that lasts for _______ Untreated CKD can result in __________ -Final stage of CKD -Results in retention of ______ -Need for ________________ Damage to kidneys is thought to be caused by _______ Early stages: There can be significant damage without ___
3 months or longer end-stage kidney disease (ESKD) uremic waste products RRT (renal replacement therapy) Dialysis, or kidney transplant prolonged acute inflammation S&S
36
ESKD- need kidney transplant, not reversable, need dialysis
37
CKD: Risk Factors / causes
Diabetes (primary cause) -More than 35% of the US population over 20 years of age has CKD -Leading cause of kidney disease in patients starting renal replacement therapy Hypertension (second-leading cause) Obesity Cardiovascular disease Glomerulonephritis Pyelonephritis Polycystic disorders Nephorsclerosis Hereditary disorders -More than 60 Congenital disorders Renal cancers
38
Stages of CKD: Stage I:
GFR > or equal to 90mL/min/1.73 m2 Kidney damage with normal or increased GFR
39
Stages of CKD: Stage II:
GFR = 60-89 mL/min/1.73 m2 Mild decrease in GFR
40
Stages of CKD: Stage III:
GFR = 30-59 mL/min/1.73 m2 Moderate decrease in GFR
41
Stages of CKD: Stage IV:
GFR = 15-29 mL/min/1.73 m2 Severe decrease in GFR
42
Stages of CKD: Stage V:
GFR < 15 mL/min/1.73 m2 End-stage kidney disease (ESKD) or chronic kidney disease
43
Stages of CKD: Stage____ need to be on dialysis
3-5
44
CKD: what to expect
Elevated serum creatinine levels Abnormal creatinine clearance Anemia Decreased erythropoietin Metabolic acidosis Abnormal calcium and phosphorus levels Fluid retention (edema and CHF) As the disease progresses: Electrolyte disturbances heart failure worsens HTN more difficult to control
45
CKD: medical management Treat underlying cause(s) Keep blood pressure _____ Renal replacement therapies (RRT) -___ referral Prevent complications:
BELOW 130/80 Early Controlling cardiovascular risk factors Treating hyperglycemia Managing anemia Smoking cessation Weight loss Exercise Reduction in salt and alcohol intake
46
Dialysis: Dialysis or renal replacement therapy is indicated when _____ and/or _____ are present. Dialysis is typically the first-line treatment vs. kidney transplantation Dialysis is divided into 2 categories: __________ is a ‘gentler’ form of dialysis that can be done in critical care settings ONLY!
advanced uremia and/or serious imbalances Hemodialysis Peritoneal dialysis Continuous renal replacement therapy (CRRT)
47
CRRT can only be done in the:
ICU because they are unstable!!
48
Hemodialysis: Hemodialysis is basically an artificial kidney -____, ____, _____ -Prevents death, but does not cure kidney disease A hemodialysis system consists of 3 parts: During dialysis, blood moves from an artery through the tubing and blood chamber, then back into the body through a vein…this occurs via an ____ Diffusion, osmosis, ultrafiltration ____ is given to prevent clotting during the dialysis circuit Most persons are dialyzed three times a week for 3-4 hours each time
Acute, chronic, ESKD Blood delivery system Dialyzer Dialysis fluid delivery system AV fistula Heparin
49
Hemodialysis Before Dialysis Assess:
Fluid status -Weight (current & previous) -Vital signs Fistula (shunt) -Feel a thrill (vibration) -Hear a bruit (swooshing)
50
Deadly complication of dialysis– S&S Priority action:
DDS (dialysis disequilibrium syndrome) Restless & disoriented Vomiting Headache Stop or slow infusion, & report to provider (can happen during or after hemodialysis)
51
Meds to hold for dialysis
ABCDD Antihypertensive A (ACE & ARBS) Lisinopril, Losartan B (Beta blockers) Atenolol, metoprolol C Ca Channel Blockers Nifedipine, Verapamil, Diltiazem D Diuretics Furosemide, Hydrochlorothiazide D Dilators Nitroglycerin Antihypertensives will bottom out BP Do not Give Heparin shot since they filter with heparin
52
Meds that are washed out during dialysis
Antibiotics Digoxin Water soluble vitamins (B, C, & folic acid)
53
Hemodialysis Monitor for: Teaching No:
Infection Bleeding Feel a thrill No restrictive clothing or jewelry No BP on affected arm No sleeping on arm No cream or lotions (infections) No lifting over 5 lbs. (no purse)
54
Hemodialysis The 5 P's
Pale skin “pallor” Paresthesia (numbness or tingling) Pulses diminished Poor capillary refill Pain (distal to shunt) First 2 P’s are serious and need to be addressed quickly (they can loose their fistula, or worse, their extremeties
55
Vascular access for: hemodialysis and CRRT
AV fistula - made by connecting a vein and an artery Best choice Optimal blood flow Lowest chance of infection Central line?
56
Peritoneal dialysis: Goals of PD are to remove toxic substances and metabolic wastes to reestablish normal fluid and electrolyte balance. Treatment of choice for clients with kidney disease who are unable or unwilling to undergo hemodialysis or kidney transplantation. A typical candidate for PD: The peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane. A sterile _____ fluid is introduced into the peritoneal cavity via an abdominal catheter (see next slide). Once this solution is in the peritoneal cavity, ____ toxins begin to be cleared from blood.
Diabetes Cardiovascular disease Those at risk for adverse effects from systemic heparin Clients with other conditions that haven't been responsive to hemodialysis, will sometimes do well with PD dextrose dialysate uremic
57
Peritoneal dialysis cont. Advantages: Disadvantages:
More freedom More control over daily activities A more liberal diet (less fluid restrictions) Improve BP control 7 days a week Need to increase protein & K+ in diet
58
Peritoneal dialysis cont Indications: Contraindications:
-Willingness, motivation & ability to do -Strong support (family & community) -Problems with HD (failing access devices, severe HTN, severe anemia, post dialysis HA -HTN, uremia, and hyperglycemia easier to manage with PD -Adhesions from previous surgery -Chronic back pain or disc disease -Severe arthritis or poor hand strength
59
Peritoneal dialysis Types: All PD involves a series of exchanges:
Acute intermittent peritoneal dialysis: Not indicated for long term Usually someone who requires immediate dialysis (referred late in stage of CKD) CAPD Continuous ambulatory peritoneal dialysis Done during the day CCPD Continuous cyclic peritoneal dialysis Done at night while you sleep Installation of dialysate (by gravity) Dwell time Drainage of fluid (by gravity)
60
CRRT: continuous renal replacement therapy Dialysis that is carried out continuously instead of over 3-4 hours, as in traditional hemodialysis cases Benefits Indicated for clients who have acute or chronic kidney disease in the following cases
-Can be initiated quickly -Do not affect hemodynamics as often as traditional hemodialysis -Used in critical care units -Too clinically unstable for traditional hemodialysis -Fluid overload secondary to oliguric kidney disease -Client with kidneys that cannot handle acutely high metabolic or nutritional needs
61
Avoid fluid excesses -Dyspnea, tachycardia, and JVD -Crackles auscultated in lungs -edema -_____________ may be prescribed for diuresis
Mannitol, furosemide, or ethacrynic acid
62
Dialysis to prevent complications of AKI
Hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema

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