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Acute and Chronic Kidney Disease Chapter 68 (3)
Terms in this set (118)
acute kidney injury (AKI)
-rapid reduction in kidney function resulting in a failure to maintain fluid and electro balance and acid base balance
-occurs over hours or days
-severity is based on serum creatinine and decreased output (decreased function) with adequate hydration
-direct measure of gfr uses a 24 our urinary creatinine analysis or the clearance of an IV administered marker like insulin, nonradiactive contrast or radioisotiope. this is done because a gfr is not good to determine aki and ckd during critical injury
-the longer the duration of oliguria (small output) and anuria (no output) the less likely the patient will return to baseline function
loss outcome (perminent damage)
end stage kidney disease (intervention or death is likely)
-stages of injury with GFR DECREASE
-causes of AKI;
are reduced perfusion to the kidneys
damage to the kidney tissue
-more likely to occur in old hospitalized adults with htn, diabetes, pvd, liver disease, or chronic kidney disease
aki caused by reduced perfusion
-most common cause of AKI in acute care
blood of fluid loss (surgery, trauma, hypovolemic)
blood pressure drugs causing hypotention
dehydration or burns
intrarenal or intrinisic renal failure
direct injury to the tissues inside the kidneys
bleeding in the kidney
glomerulonephritis or inflammation of the glomeruli
obstruction of the urine flow
bladder, cervical, colon, prostate cancers
acute on chronic kidney disease
when AKI occurs with someone who has CKD
compensation with prerenal or postrenal pathology
constricting blood vessels
activate renin-angio-aldosterone pathway
-these responses increase blood flow the the kidneys
-these responses also result in oliguria and azotemia (buildup of nitrogenous waste in the blood)
health promotion and maintenance
-severe blood loss can cause kidney injury in someone who has no history at all
-2-3L a day to avoid dehydration (less volume)
-accurately measure i and o's in hospital setting and daily weights
-notify hcp if urine is less than 0.5ml/kg/hr that persists for more than 2 hours
-waiting more than 6 hours of oliguria to meet RIFLE criteria may promote kidney damage, act early
-increase in creatinine is a big concern and should be reported
-BUN, serum potassium, na, osmolarity, and urine gravity
aminoglycoside antibiotics (gentamicin)
chemotherpay agents (cisplatin)
NSAIDs (celecoxib, flurbiprofen, ibuprofen, ketorolac)
other drugs (tylenol, captopril)
organic solvents (carbon tetrachloride)
non-drug chemical agents pesticides)
heavy metals and ions (arsenic, bismuth, copper, lead)
-ask about any recent trauma that may decrease blood flow
-diseases that may hurt kidneys such as diabetes, age, htn, lupus, sepsis, inflammation, coagulation therapy
-changes in urine output or color
-anticipate AKI following any episode of htn, shock, burns, or heart failure
-any problem depleting blood volume can cause AKI such as bowel preperations, NPO, dehydration from exercise
-history of urinary problems? difficulty starting and keeping a urine stream, nocturia, urgency, kidney stones? cancer?
older adults: decreased
in chronic kidney disease: slow increase
acute kidney injury: rapid increase, 80-100 in a week
BUN blood urea nitrogen
older adults: slight increase
chronic kidney disease: 180-200 before manifestations begin
acute: may reach 80-100 within 1 week, again rapid
clinical manifestations of AKI
-related to buildup of nitrogenous wastes (azotemia), decreased urine output, as well as the underlying cause
-may develop symptoms of fluid overload (not excreting)
-check for crackles, dyspnea, tachycardia, edema, down o2
-a rising serum creatinine is a sign of prolonged or permanent kidney damage
-expect to see rising BUN levels and altered electro levels
-urine may be dilute with a low gravity
-nephron damage might have occurs, rbc, wbc present
-ultraonography is useful in the diagnosis of kidney and urinary tract obstruction
-ct scan without contrast to determine adequacy of kidney blood flow and any tumors or obstructions
-contrast dyes are usually avoided
-x-ray of KUB, pelvis to find any obstructions or alterations
an 84 year old male is being admitted after surgery and has history of hypertension. he has a cloudy urine in his catheter bag of 100ml after 3 hours. what is appropriate?
notify the hcp.
this output is not sufficient enough and after 2 hours the hcp should be notified. you wouldn't increase fluids because if the kidneys aren't functioning you are going to put them into fluid overload. you wouldn't ask someone their normal pattern when they have a tube up their dick.
interventions for AKI
-observe for any signs such as edema, weight gain, and reduced urine output is huge. 0.5ml/kg/hour
-blood sampling to water their labs and elevated serum critinine
-AKI can also have high output (polyuria) from proteins
-frequent serum monitoring, watching I and O's, drug therapy nutrition and careful fluid therapy are common
drug therapy for AKI
-as kidney function changes, drug doses change!
-diuretics may be used to increase output but does not preserve kidney function or stop AKI
-calcium channel blockers may be used
-catabolism may be occurring (protein breakdown)
-high protein diets usually
-nutrition support is needed for the severely ill
renal replacement therapy (dialysis)
- used for patients with loss of kidney function
-used for symptomatic uremia (pericarditis, neuropathy)
-can remove toxins such as high K or acidosis (lowered ph)
-access is made by a vascular access with a catheter specific for dialysis
-the catheter is not used for blood samples, drugs, or fluid, it is strictly for filtering blood
-inserted into the jugular vein using strict aseptic technique
-has 2 lumens, one for outflow (into machine) and one for inflow (back into the body)
intermittent versus continuous dialysis
-this is a way to substitute kidney function
-intermittent renal replacement therapy (rrt) sometimes is called hemodialysis over 3-6 hours
-dialysate is the fluid used that helps remove the unwanted particles and waste from the persons blood.
-dialysate is prescribed by the hcp
continuous renal replacement therapy
-also known as hemofiltration
-used for patients who are too unstable to tolerate changes in blood quickly that occur with intermittent
-returns blood over 12-24 hours a day
-hemofiltration uses ultrafiltration whereas diffusion is used in intermittent
-ultrafiltration is the separation of particles from a suspension by passage through a filter with fine pores
continuous renal replacement therapy continued
only occurs in the ICU because of;
need for frequent monitoring by a specialist
need for ongoing replacement of fluid and electrolytes
the nurse is discharging someone but notices their serum potassium was 5.8 which is a priority nursing action
-don't tell them to drink 500ml of water to dilute it
-don't encourage to eat k binding foods and contact hcp in 24 hours
-don't apply a cardiac monitor and evaluate the results
-check all the values looking for abnormalities and contact the hcp before the client is discharged. this is a significant increase and something needs to be done before the client goes home
depends on the severity of the AKI
-if the kidneys are recovering there will be follow up care but not as extensive
-scheduled lab blood tests and urine tests to monitor function
-if the patient needs dialysis they will need nursing and social work assistance
chronic kidney disease
-progressive, irreversible disorder and kidney function does not recover
-when kidney function becomes to poor to sustain life, this is considered end stage kidney disease (eskd)
-azotenia = buildup of nitrogen-based waste )
uremia= azotemia with clinical manifestations
stages of chronic kidney disease: stage 1
at risk with normal kidney function but urine findings or structural abnormalities or genetic trait point to possible kidney disease
-gfr = 90ml/min
interventions: screen for risks such as htn, diabetes, uti, family history, exposure to nephrotoxic substances
stage 2 of CKD
mild chronic kidney disease, lab findings and structural findings point to kidney disease
-nephron damage has occurred
-increased output of diluted urine may be increased
gfr = 60-89ml/min
interventions: focus on reduction of risk factors
stage 3 of CKD
GRF reduction continues and ranges between 30-59ml/min
-nephron damage is greater and azotemia is present
-ongoing management of what caused the nephron damage is essential
-restriction of fluids, proteins, and electros is needed
stage 4 of CKD
considered severe CKD
-GFR of 15-29
-manage complications and educate about their option for renal replacement therapy
stage 5 of CKD
end stage kidney disease (ESKD)
-death occurs without renal replacement therapy
-less than 15ml/min GFR
uremia key features (waste in blood with manifestations)
metallic taste in mouth
frost on skin
itching, fatigue, lethargy
-CKD with GFR issues causes many problems including abnormal urine production, severe disruption of electrolyte balance, and metabolic abnormalities
-kidneys can work hard even when 3/4 of function is lost
-over time BUN increases and urine output decreases
-urea and creatinine excretion are disrupted by CKD
-creatinine comes from proteins present in skeletal muscle. the rate should be constant without much change
-with decreased function their is a buildup of serum creatinine
-urea is made from protein metabolism and is excreted by the kidneys. the bun level will normally vary with protein intake
-Na is rapidly lost in urine with early CKD because of an inability of the nephrons to reabsorb these electros
-kidney excretion of sodium is lost as urine production decreases in later stages. sodium retention causes htn and edema
-become more acidic with decreased ammonium production and re absorption of bicarbonate is lost.
-respiratory compensation occurs to keep ph normal
-kussmaul respiration = increases with worsening kidney disease
metabolic changes continued
calcium and phosphorus balance is disrupted
-lose of bone density can occur over time from PTH
hypertension is common in most patients with CKD
-can be the cause or result
-dysfunction of the renin-angio system can occur
-htn and CKD is difficult to manage because of their cycling relationship
-hyperlipidemia can occur with CKD
-heart failure can occur with CKD from fluid overload
common in later stages due to the decreased erythropoietin production that is a kidney function
anorexia, n/v is common with uremia
-peptic ulcer disease is common in patients with uremia
two main causes
hypertension and diabetes
african americans more likely to develop eskd
life style modifications and alterations
early on you must manage the disease that can cause ckd including diet adjustments and weight management
-adhere to drug therapy and diet regimens and participate in physical activity
-drug therapy with hypertension and diabetes to reduce arteriole damage
-nsaids reduce blood flow to the kidneys and long term use can reduce kidney function
history and chronic kidney disease
document age and gender
any weight gain?
any change in the taste of foods? uremia possible
fatigue is common with CKD especially with dialysis
clinical manifestations of CKD
neurological manifestations (seizures to coma)
cardiovascular changes (fluid overload, htn, hf)
respiratory manifestations (metabolic acidosis)
hematological manifestations (altered erythopoietin)
GI manifestations (foul breath and mouth inflammation)
skeletal manifestations (poor absorption of calcium)
urine manifestations (kidneys decreased function)
skin manifestations (yellowish coloration from uremia)
ask about their understanding of the diagnosis
anxiety and coping style as life changes will occur
creatinine, BUN, sodium, potassium, calcium, phos, bicarbonate, hemoglobin, hematrocrit, gfr for trends
-urinalysis is performed. everything will be elevated.
-gfr with a urine collection of 3-24 hours is done
-creatinine and BUN levels should be monitored
excess fluid volume r/t inability to excrete
potential for pulmonary edema r/t fluid overload
decreased cardiac output
inadequate nutrition r/t inability to ingest, digest, or absorb
risk for infection
risk for injury
fatigue r/t kidney disease, anemia, and reduced energy
anxiety r/t a threat of well being
renal replacement therapy
is needed when the pathologic changes of stage 4 and stage 5 CKD are life threatening or poses issues
-dialysis is a last resort therapy as well as transplantation
intermittent hemodialsis is the most common RRT used with ESKD
-removes fluids and waste and restores chemical balance
-therapy includes passing the patients blood through a semi-permiable membrane that stops the unwanted particles
-usually started when uremsis is present (n/v, decreased attention span, pruritus)
dialysis is started for anyone with
does not depend on the GFR alone
-fluid overload that is not responding to diuretics
-symptoms of hyperkalemia
-calciphylaxis (thombosis and skin necrosis from stg 5 CKD)
-symptoms of toxin ingestion such as drug overdose
-many settings depending on their specific needs
-may be done in hospital if it is complicating and needs close supervision
-dialysis works by difusion
-diffusion is the movement of moleculres from an area of high concentration to lower concentration
-when HD is started, blood and dialysate flow in opposite directions across the semipermeable membrane. the dialysate contains a balance that closely resembles human plasma. the waste product from the blood moves into the dialysate
-heparin therapy is used with dialysis as blood clotting can occur with dialysis and stays for 4-6 post procedure
HD system includes
dialyzer (artifical kidney)
dialysate (solution used to diffuse waste products, 100F)
vascular access routes
HD machine (detects v/s and abnormalities, alarms set)
required for hemodialysis
-gives access to a large amount of blood flow 250-300ml/min for 3-4 hours
-long term access: internal arteriovenous fistula / AV graft
-AV fistula needs time to mature by thickening vessel walls
-can take as long as 4 months and if this is unsuccessful they are considered for the AV graft, common in old patient
common complications with access;
thrombosis / stenosis (clotting of the access)
infection (staph during cannulation)
aneurysm formation (repeated needle punctures)
ischemia (steal syndrome, fistula decreases blood flow below it)
heart failure (shunting blood from arterial system to the venous system through the fistula can cause HF)
internal anastomosis of an artery to a vein
forearm, upper arm
2-4 months to use because you need the vein to be "mature"
synthetic vessel tubing connecting an artery and a vein
forearm, upper arm, inner thigh
1-2 weeks before you can utualize it
temporary placement with outflow and inflow placement
subclavican, internal jugular, femoral vein
can be used immediately after surgery with x-ray to confirm
internal device with two metallic access ports and two catheters inserted into two large central veins
immediately aftet placement with x-ray comfirmation
used for someone waiting for permanent access or kidney
hemodialysis nursing care
some drugs should be held until after treatment because they can easily be dialysed
-treatment can take 4-8 hours
monitor for side effects for several hours
common problems include:
hypotension, headache, n/v, dizzy, muscle cramps
they are severely exhausted after this procedure
-avoid injury from the heparin
-their temp may be elevated because blood is slightly warm
-gather their weight may be lower and hypotensive from the removal of waste
complications of hemodialysis
dialysis disequilibrium syndrome (mental status change)
cardiac events (usually with present issues)
reactions to dialyzers (looks like anaphylaxis, rare, first time?
- you should slow or stop the machine when manifestations occur
-hypoglycemia common for diabetic patients
-contaiminated blood worries (hep b + c, reduced worry)
care for the patient undergoing hemodialysis
-weight before and after
-know the patient's dry weight
-discuss any drugs that should be help prior to treatment
-be aware of manifestations of adverse effects
occurs in the peritoneal cavity rather than the arm
-slower than hemodialysis
-increased protein loss in outflow, risk of injury to peritoneal, potential discomfrt from indwelling fluid
-not very common anymore
PD is less hazardous if you can not tolerate anticoagulation needed for HD
-can be used until a fistula is mature, or a patient simply can't tolerate a fistula
-treatment of choice for the older patient
siliconized rubber catheter is surgically placed into the abdominal cavity for infusion of dialysate
-1-2L of dialysate is infused by gravity into the peritoneal space over 10-20 minute period according to tolerance
-the fluid stays (dwells) in the cavity for a prescribed time and flows out by gravity into a drainage bag
-peritoneal outflow contains dialysate and excess water, electrolytes, waste product
-called peritoneal effluent outflow
-three phases: infusion, dwell, and outflow
-occurs through diffusion and osmosis across the permeable pertoneal membrane and capillaries
-peritoneal membrane is large and porous allowing solutes and water to move from high to low concentration in the dialyzing fluid
-peritoneal cavity is rich in capillaries and is a good blood supply
heparin (again) may be used to prevent clotting of the catheter of tubing
-intraperitoneal heparin for new catheter placement (is not absorbed sytemically and does not affect clotting)
-potassium and antibiotics may be added to dialysate these things are not stock but added based on patients needs
types of peritoneal dialysis
continuous ambulatory PD
multiple bag continuous ambulatory PD
continuous cycle PD
-continuous ambulatory and continuous cycling most common
continuous ambulatory peritoneal dialysis (CAPD)
-performed by the patient with infusion of 4 2L exchanges of dialysate into the cavity
-remains for 4-8 hours each time occur 7 days a week
-patient can use continuous connect system or disconnect system, most patients do it overnight with an automated cycler
-disconnecting system the patient can remove the connecting tubing and empty the dialysate bag after inflow and attaches a cap to the PD catheter. this eliminates the need to wear a tube and bag, this also increases infection
-no machine is needed or a partner
continuous cycle peritoneal dialysis (CCPD)
automated cycling machine
exchanges occur at night when you sleep
24 hour dialysis, similar to CAPD but less manuevering the tubes
automated peritoneal dialysis (APD)
acute care setting
cycling machine for inflow, dwell and outflow with a warming chamber
30 minute exchange 10/10/10 for 8-10 hours
-can be used to deliver large volumes of dialysis and also permits home dialysis and can be asleep while this occurs
intermittent peritoneal dialysis (IPD)
2L exchange at 30-60 minute intervals allowing 20 minutes for drain time
-30 to 40 exchanges of 2 L three times week needed
complications with PD
peritonitis is the major concern (contaimination caused)
mainfestations of peritonitis: cloudy dialysate outflow, fever, abd tenderness, abd pain, malaise, n/v
-clody outflow is the earliest manifestation
-send specimen of outflow for c+s, gram, cell count to identify organism
other complications with PD
pain during inflow is common for rookies
-usually no longer than 1-2 weeks
-warm the bags before instillation with a heated pad
-do not microwave the bag
exit site and tunnel infection are serious complication
-should be clean, dry without pain or inflammation
-exist site infection can occur with any PD catheter
-can lead to peritonitis, catheter failure, and hospital
tunnel infections occur in the path of the catheter
-redness, tenderness, pain, may need catheter removal
poor dialysate flow is usally r/t constipation
-bowel prepartion is prescribed before placement of PD
-enema may also be indicated, eat high fibers, softeners
seen as clear fluid coming from the exit site
-more often in obese, diabetes, old, long term steroid use
-if leaking occurs may need HD support
more complications of PD
bleeding is expected for first week
-effluent should be clear or light yellow
-brown colored effluent may be a bowel perforation
nursing care during peritoneal dialysis
in the hospital setting PD is routinely started and monitored by a nurse
-before treamtent = v/s, weigh the patient, labs, v/s every 30 minutes during cycling
-observe outflow pattern (continuous stream after the clamp is open)
-accurate input and output (what you put in comes out)
-not considered a cure
-must be free of medical problems
-can't not have cardiac disease
-cancer, infection, alcohol, chemical dependency
-urinary system is evalauted to ensure urine flow
-diabetes a great risk but you can have it
living donors (highest success rate at 90)
dead donors (immidetately harvested post death)
cadaveric donors (brain damage)
no infection of systemic disease
no htn or kidney disease
adequate function by diagnostic studies
-body can attack the foreign tissue
-must be the same blood type
-human leukocyte antigen (HLA) should be similar to avoid attacking the organ
-teaching and assessment, tests, development of a plan
-required dialysis within 24 hours of surgery and blood transfusion before surgery (may be donor blood)
laparoscopic procedure for a living donor
-transplanation takes several hours
-iliac fossa for aplacement for easier connection of the ureter and artery and vein renal
-old kidney is not removed unless it is infected or causes pain (polycystic kidney disease)
evaluation of kidney function
rejection and infection most common
catheter placed for accurate measure of output
assess output hourly for 48 hours
urine may be pink for a few days
daily urine speciemens for urinalysis, glucose, sgm, culture
bladder irrigation to decrease blood clot formation
diuretics to increase output may be given
patient may have diuresis (especially from a living donor)
rejection is the most serious complication
three forms of rejection: hyperacute, acute, chronic
-acute rejection is the most common, treated with immunosuppressive therapy and often can be reversed
-ischemia from delayed transplanation can cause AKI
-thrombosis os renal vessels for 2-3 day risk
-renal artery stenosis from htn, bruit heart,
within 48 hours after surgery
increased temp, increased bp, pain at site
treatment: immediate removal of the tranplanted kidney
1 week to any time postop, days to weeks
oliguira or anuria, temp over 100F, increased BP, enlarged tender kidney, elevated creatinine, BUN, potassium, retention
treatment: increased doses of immunosuppressive therapy
months to years
gradual increase in BUN and creatinine
fluid rention or electrolyte changes, fatigue
treatment: conservation until dialysis is needed
inhibitors of T-cell proliferation (azathioprine, mycophenolic)
-make sure patient adheres to therapy
home care management
hemodialysis HD (extensive home care system)
peritoneal dialysis PD (extensive training in procedure)
transplanation (take your immunosuppresive drugs)
self management education
-HD is the most complex form of therapy
-care for vascular access ports and report infection
-at home HD will need a partner
-PD involves extensive teaching and understanding. use of sterile technique to avoid peritonitis
-IP route if infection may have occured
what might you notice if someone is experiencing reduced perfusion and altered urinary elimination r/t AKI?
hypotension and teachycardia persisting
urine ouput less than 0.5ml/kg/hr
serum creatinine increases (not pissing out the creatinine)
back or flank pain
urine sediment (blood)
signs of electro imbalances
Which factor represents a sign or symptom of digoxin toxicity?
Visual changes, anorexia, nausea, and vomiting are symptoms of digoxin toxicity. A digoxin level of 1.2 ng/mL is normal (0.5-2.0 ng/mL). Polyphagia is a symptom of diabetes. Although hypokalemia may predispose to digoxin toxicity, this represents a normal, not low, potassium value.
A client awaiting kidney transplantation states, "I can't stand this waiting for a kidney, I just want to give up." Which statement by the nurse is most therapeutic?
you sound frustrated with the situation.
Acknowledging the client's frustration reflects the feelings the client is having and offers assistance and support. Talking to the health care provider and removing the client from the waiting list does not allow the nurse to hear more and perhaps offer therapeutic listening or a solution to the problem. Telling the client that the wait is endless for some people cuts the client off from sharing his or her concerns and accentuates the negative aspects of the situation. The waiting time for kidney matches is increasing due to a shortage of organs; the nurse should not offer false hope by suggesting that the client will get a phone call soon.
Which finding in the first 24 hours after kidney transplantation requires immediate intervention?
abrupt stopping of output
An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury, thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output are expected findings after kidney transplantation.
The nurse wishes to reduce the incidence of hospital-acquired acute kidney injury. Which question by the nurse to the interdisciplinary health care team will result in reducing client exposure?
"Can we use less radiographic contrast dye?"
Contrast dye is severely nephrotoxic and other options can be used in its place. Air circulation and low-dose dopamine are not associated with nephrotoxicity. Prerenal status results from decreased blood flow to the kidney, such as fluid loss or dehydration; IV fluids can correct this.
When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider?
temp of 100.8
Infection is a major complication of temporary catheters. All symptoms of infection, including fever, must be reported to the provider because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During acute injury, oliguria with resulting fluid retention is expected. Rising blood urea nitrogen (BUN) may result in anorexia, nausea, and vomiting.
Which instruction does the nurse provide to a client with hypertension and diabetes to prevent or delay the onset of chronic kidney disease (CKD)?
adhere to diet and drug therapy
The client with hypertension and diabetes must strictly adhere to drug and diet regimens to prevent blood vessel changes that lead to kidney damage. These medications are not a cure but need to be taken along with changes in lifestyle. The client must test for microalbuminuria every year for early detection of the disease. The client must restrict the use of over-the-counter drugs or NSAIDs as they reduce blood flow to the kidney and their long-term use reduces kidney function.
Discharge teaching has been provided for a client recovering from kidney transplantation. Which information indicates that the client understands the instructions?
antirejection meds will be taken for life.
Immune-suppressant therapy must be taken for life to prevent organ rejection. Adherence to immune-suppressive drugs is crucial to survival for clients with transplanted kidneys. Lack of adherence can lead to complications such as rejection, graft loss, return to dialysis, and death. Oliguria is a symptom of transplant rejection; the transplant team should be contacted immediately if this occurs. It is not necessary to take antirejection medication with 8 ounces of water.
A client receiving hemodialysis is prescribed folic acid and ferrous sulfate orally. What does the nurse teach the client about folic acid therapy?
take it after dialysis
The client receiving dialysis loses vital vitamins and minerals from the blood in the process. Therefore, folic acid supplements must be taken after dialysis. Clients should avoid antacids within 2 hours of taking cardiac glycosides; antacids interfere with the absorption of the drug. Iron supplements, not folic acid, cause a normal change in the color of the stool. This client should take stool softeners to prevent constipation.
The nurse instructor is teaching a group of nursing students about acute rejection of kidney transplantation. What statement made by the nurse instructor is accurate?
"Increased doses of immunosuppressive drugs are used to treat and manage acute rejection."
Acute rejection of kidney transplantation is an immune reaction and is managed by increased doses of immunosuppressive drugs. Hyperacute rejection manifests as pain at the transplant site. Hyperacute rejection occurs within 48 hours after the surgery. Chronic rejection causes a gradual increase in BUN levels.
What does the nurse identify as a possible cause of postrenal acute kidney injury (AKI) in a client?
Urethral stricture is a cause of postrenal AKI. Postrenal AKI is the obstruction of the urine collecting system. Exposure to nephrotoxins and acute tubular necrosis are causes of intrarenal AKI. Intrarenal AKI is actual physical, chemical, hypoxic, or immunologic damage directly to the kidney tissue. Pulmonary embolism is a cause of prerenal AKI. Prerenal AKI is a decrease in blood flow to the kidneys, leading to ischemia in the nephrons.
What intervention is appropriate for the client with stage 4 chronic kidney disease (CKD)?
Managing complications and preparing for renal replacement
CKD is a progressive, irreversible disorder divided into five stages. Interventions for stage 4 CKD include managing complications and preparing for renal replacement therapy. Interventions for stage 3 CKD include implementing strategies to slow the disease progression. Interventions for stage 2 CKD include focusing on the reduction of risk factors such as diabetes mellitus. Interventions for stage 5 CKD include kidney transplantation.
The nurse is caring for a dialysis client with a very poor appetite. What action does the nurse take?
Administer total parenteral nutrition as prescribed.
The client on dialysis with a very poor appetite is administered total parenteral nutrition as prescribed. This provides the client with sufficient nutrition to preserve lean body mass and maintain fluid balance. The client on dialysis is prescribed 1 to 1.5 g/kg of protein in the diet whereas 40 g/day of protein is prescribed for the client without dialysis. Generally, the client is allowed fluid intake equal to urine output plus 500 mL. The client's diet should include potassium intake up to 60 to 70 mEq.
Which clinical manifestation indicates the need for increased fluids in a client with kidney failure?
An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration.
Which nephrotoxic nonsteroidal anti-inflammatory drug (NSAID) can cause acute kidney injury (AKI) in clients?
A client is scheduled to undergo kidney transplant surgery. Which teaching point does the nurse include in the preoperative teaching session?
"It is essential for you to wash your hands and avoid people who are ill."
Antirejection medications increase the risks for infection, sepsis, and death. Strict aseptic technique and handwashing are essential. Unless severely infected, the client's kidneys are left in place and the graft is placed in the iliac fossa. Dialysis is performed the day before surgery; after the surgery, the new kidney should begin to make urine.
The nurse is caring for a client with prerenal failure. What is the cause of this AKI?
Traditionally, AKI caused by reduced perfusion is classed as prerenal failure. It is the most common cause of AKI in acute care. Damage to kidney tissue is classed as intrarenal or intrinsic renal failure and reflects injury to the glomeruli, nephrons, or tubules. Obstruction of urine flow is also called postrenal failure.
The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? Select all that apply.
Breakdown of protein leads to azotemia and increased blood urea nitrogen (BUN). Fluid is restricted during the oliguric stage. Potassium intoxication may occur, so dietary potassium is also restricted. Sodium is restricted during AKI because oliguria causes fluid retention. Fats may be used for needed calories when proteins are restricted.
A client with acute kidney injury (AKI) is scheduled to undergo dialysis. What types of nutritional therapy may be required for the client? Select all that apply.
Total parenteral nutrition (TPN)
Fluid intake equal to urine output plus 500 mL
The very ill client with AKI is usually administered TPN. This provides the client with sufficient nutrition, preserves lean body mass, and maintains fluid balance. Generally, the client is allowed fluid intake equal to urine output plus 500 mL. The client on dialysis is prescribed 1 to 1.5 g/kg of protein in the diet, whereas 40 g/day of protein is prescribed for the client without dialysis. The client's diet includes a potassium intake of up to 60 to 70 mEq and a sodium intake of up to 60 to 90 mEq.
The classification of acute kidney injury (AKI) in a client is based on the five criteria called RIFLE (Risk, Injury, Failure, Loss and End-stage kidney disease). Which criteria are categorized as reversible severity levels? Select all that apply.
risk injury and failure can be reversible
What laboratory changes does the nurse expect in a client with chronic kidney disease? Select all that apply.
BUN and creatinine
At a health fair, the nurse is teaching attendees about acute kidney injury (AKI). What statement made by a participant indicates a need for further teaching?
AKI effects every body system
Chronic kidney disease, not AKI, affects every body system. AKI affects some body systems. The onset of AKI is sudden and involves around 50% of nephrons. The duration of AKI is around 2-3 weeks and is usually less than 3 months.
The nurse is teaching a client about preventing kidney problems. What does the nurse instruct the client? Select all that apply.
educe the intake of carbonated soft drinks.
Report any discomfort with the passage of urine.
Have kidney function checked at least once a year.
Report any change in frequency or volume of urine
The client should avoid carbonated soft drinks because they contain artificial sweeteners and are not beneficial to the kidney. Any discomfort with the passage of urine is not normal and must be reported to the health care provider. The client must have kidney function checked at least once a year; changes in kidney function are often silent for many years. The client must report any change in frequency or volume of urine because these are signals of potential problems and must be resolved at the earliest. The client must take at least 3 L of fluids, mainly water to flush the kidney thoroughly.
What are the main causes of end-stage kidney disease (ESKD)? Select all that apply.
diabetes and htn
According to the United States Renal Data System (USRDS), diabetes mellitus and hypertension are two of the main causes of ESKD. Genetic kidney disease and infections such as tuberculosis and pyelonephritis are other causes of ESKD, but they are not the main causes.
The nurse is caring for a client with chronic kidney disease. What are some complications the nurse should be aware of after hemodialysis? Select all that apply.
Infection, hypotension, back and flank pain
Complications associated with the use of hemodialysis include disequilibrium, muscle cramps and back pain, headache, itching, adverse cardiac and hemodynamic events, and infection. Complications associated with peritoneal dialysis include protein loss, hyperglycemia from dialysate, respiratory distress, infection, and weight gain.
A female client has acquired a urinary tract infection (UTI) for the second time. What does the nurse instruct the client to prevent future infections? Select all that apply.
loose fitting cotton underwear
2 tablespoons of apple vinegar 3 times daily
take meds as directed
The client with a UTI should wear loose-fitting cotton underwear and avoid wearing irritating clothing such as nylon underwear. Apple cider vinegar helps to acidify the urine in the bladder and prevent infections. The client can prevent recurring infections by taking prescribed antibiotics as directed and scheduling a follow-up appointment with the health care provider. A daily intake of 500 mg of vitamin C helps to acidify the urine. The client must clean the perineal area from front to back to prevent organisms in the stool from coming close to the urethra and causing an infection.
The nurse is caring for a client who underwent placement of an arteriovenous fistula. What is the priority postoperative intervention for this client?
Instruct the client to elevate the extremity postoperatively.
The client should elevate the extremity postoperatively to prevent edema at the site. The nurse must not monitor blood pressure or start an IV line in the extremity with the fistula because repeated compression can result in loss of the vascular access. The nurse should palpate the area for thrills and auscultates for bruits every 4 hours.
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