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Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease Outline

Terms in this set (35)

Kidney Function Blood Studies:
Serum Creatinine:
Males- 0.6-1.2 mg/dl
Females- 0.5-1.1 mg/dl

Significance of Abnormal Findings:
- An increased level indicates kidney impairment
- A decreased level may be caused by a decreased muscle mass

Blood Urea Nitrogen (BUN):
10-20 mg/dl

Older Adults:
60-90: 8-23mg/dl
> 90: 10-31 mg/dl

Significance of Abnormal Findings:
- An increased level may indicate liver or kidney disease, dehydration, or decreased kidney perfusion, a high-protein diet, stress, steroid use, GI bleeding,or other situations in which blood is in body tissues
- A decreased level may indicate malnutrition, fluid volume excess, or severe hepatic damage

BUN/Creatinine Ratio:
6-25 (BUN divided by Creatinine)

Significance of Abnormal Findings:
- An increased ratio may indicate fluid volume deficit, obstructive uropathy, catabolic state, or a high-protein diet
- A decreased ratio may indicate fluid volume excess

Specific Gravity: 1.005 - 1.030

pH: Average: 6; POssible range: 4.6-8

Protein: 0-0.8 mg/dl

Glucose: Negative from fresh specimen

Ketones: None
Billirubin: None
Parasites: None
Bacteria: <1000 colonies/mL
Leukoesterase: None
Nitrites: None
Kidney Disease Laboratory Profile: P. 1415
Serum Creatinine:
Male: 0.6-1.2 mg/dl
Female: 0.5-1.1 mg/dl
Older Adults: Decreased

Values in Kidney Disease:
In CKD:
- May increase o.5-1.0 mg/dl every 1-2 years
- May be as high as 15-30 mg/dl before manifestations of severe ckd are present

Values in Acute Kidney Injury:
- Increase of 1-2mg/dl every 24-48 hr
- Increase in 1-6mg/dl in 1 week or less

Blood Urea Nitrogen:
10-21 mg/dl
Older Adults: Slightly increased

In CKD:
May reach 180-200 mg/dl before manifestations develop

In AKI:
Often increases by 10-20 mg/dl at same pace as serum creatinine
May reach 80-100mg/dl within 1 week

Serum Sodium: 136-145 mEq/L
Normal, increased; or decreased

Serum Potassium: 3.5-5.0 mEq/L
Increased

Serum Phosphorous (Phosphate): 3.0-4.5 mg/dl
Increased

Serum Calcium:
Total Calcium: 9.0-10.5mg/dl
Ionized Calcium: 4.5-5.6 mg/dl
Older Adults: Slightly Decreased
Decreased

Serum Magnesium: 1.3-2.1 mEq/L
Increased

Serum Carbon Dioxide Combining Power (Bicarbonate):
23-30 mEq/L
Decreased

Arterial Blood pH: 7.35-7.45
Decreased (Metabolic Acidosis) or Normal

Arterial Blood Bicarbonate:
21-28 mEq/L
Decreased

Arterial Blood PACO2:
35-45 mm Hg

Hemoglobin:
Female: 12-16 g/dl
Male: 14-8 g/dl
Older Adults: Slightly Decreased
Value: Decreased

Hematocrit:
Female: 37-47%
Male: 42-52%
Older Adults: Slightly decreased
Value: Decreased

Blood Osmolarity: 285-295 mOsm/kg
Elevated in volume-depleted state, increasing the risk for acute kidney injury
Acute Kidney Injury (AKI):
Pathophysiology:
- AKI is a rapid reduction in kidney function resulting in a failure to maintain fluid and electrolyte balance and acid-base balance

- Severity is based on increases in serum creatinine and decreased urine output

- Occurs most often in hospitalized adults who are older or how have pre-existing hypertension, diabetes, peripheral vascular disease, liver disease, or chronic kidney disease

Types:
- Prerenal-Reduced perfusion
- Intrarenal-Damaged kidney tissue
- Postrenal- Obstruction of urine flow
- Prerenal azotemia

Causes:
- Hypovolemic shock
- Heart failure

Health Promotion:
- Accurately measure intake and output and cjeck body weight to identify change sin fluid balance
- Report to HCP a urine output of less than 0.5mL/kg/hr
- SIgnificant increase in creatinine, especially hen the increase occurs over hours or a few days, is a concern and should be reported urgently to HCP
- If a patient is to receive a known nephrotoxic drug, closely monitor lab values, including BUN, creatinine, and drug peak and trough levels for indications of kidney function

Objective and Subjective Data:
- Increased Creatinine, BUN, Nephrotoxic substances, oliguria

- Pain in the flank area

- History of cancer- Urinary obstruction
Phases of Acute Kidney Injury:
- Rapid decrease in kidney function leads to collection of metabolic wastes in the body

Phases:
- Onset
- Oliguric
- Diuretic
- Recovery

- Acute syndrome may be reversible with prompt intervention
Patient Care for AKI:
Assessment:
- Ask about recent surgery or trauma, transfusions, or other factors about recent surgery or trauma that might lead to reduced kidney blood flow
- Obtain drug history, especially antibiotcs and NSAIDs
- Coexisting conditions: advanced age, diabetes mellitus, long-term hypertension, systemic lupus, major or systemic infection (sepsis), systemic inflammation
- Anticipate AKI following hypotension, shock, burns, or heart failure exacerbation
- Hx of urinary obstructive problems
- Cancer history that may cause urinary obstruction

Physical Assessments:
- AKI progresses that patient may: Develop fluid overload, including pulmonary crackles, dependent and generalized edema, decreased oxygenation, increased respiratory rate and dsypnea.

Lab Assessment:
- Rising creatinine
- Rising BUN and abnormal electrolyte values
- Urine may be dilute with a specific gravity near 1.000 or concentrated with a gravity greater than 1.030

Imaging Assessment:
- Ultrasonography diagnoses kidney and urinary tract obstruction

- CT scans with dye can determine adequacy of kidney blood flow and identify obstruction or tumors

- X-Rays of the (KUB) may b used to provide initial screening

Other Diagnostic Assessment:
- Kidney biopsy is performed if the cause of AKI is uncertain and manifestations persist or an immunologic disease is suspected

Interventions:
- Current guidelines suggest that a mean arterial pressure (MAP) of 65 mm Hg be maintained to promote kidney perfusion
- Not all patients have oliguria
- During AKI, with high-volume urine output, hypovolemia and electrolyte loss are the main problems

Drug Therapy:
- In patients with fluid overload, 500 - 1000mL of nss may be infused over 1 hour

Nutrition:
- Have a high catabolism of protein breakdown
- Catabolism causes the breakdown of muscle for protein and increases azotemia
- For the patient who does not require dialysis, 0.6g/kg of body weight or 40g/day of protein
- For patients who require dialysis, protein level needed with range from 1-15g/kg
- As a rule, special tube feedings or kidney patients are lower in NA, K, Phosphorous, and higher in calories than standard feedings
Chronic Kidney Disease (CKD):
- Slow, progressive, irreversible kidney injury; kidney function does not recover

- End-stage kidney disease (ESKD)
- Azotemia: Buildup of nitrogen-based wastes in blood

- Uremia: a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys.
Key Features:
- Metallic taste in mouth
- Anorexia
- N&V
- Muscle Cramps
- Uremic "Frost" on Skin
- Itching
- Fatigue and Lethargy
- Hiccups
- Edema
- Dyspnea
- Paresthesias

- Uremic syndrome: a serious complication of chronic kidney disease and acute kidney injury (which used to be known as acute renal failure)
Uremic Frost
Urea crystals and salt
Stages of CKD:
- Reduced renal reserve

- Reduced glomerular filtration rate (GFR)

- ESKD-End stage kidney disease

- Severe impairment of fluid and electrolyte balance and acid-base balance

- Without replacement and therapy death can occur

Kidney changes:


Metabolic changes:
- Urea and creatinine


Electrolyte changes:
- Sodium
- Potassium
- Acid-base imbalance
- Calcium and phosphorus

Cardiac changes:
- Hypertension
- Hyperlipidemia
- Heart failure
- Pericarditis
- Hematologic changes
- GI changes
Clinical Manifestations for CKD:
Neurologic- Lethargy, Depression

Cardiovascular- Hypertension

Respiratory- Dyspnea

Hematologic- Anemia: decreased erythropoetin

GI- Nausea and vomiting

Skeletal- Bone disease from hypocalcemia

Urinary- Progression from polyuria, to oliguria to anuria

Skin- Darkening or yellowing of skin tone
Assessments for CKD:
Psychosocial: Depression

Laboratory:

Imaging:
Priority Nursing Care:
Dietary restrictions:

Uremic frost:

Muscle strength, energy:

Family members:

Excess fluid volume:

Decreased cardiac output:

Recombinant human erythropoietin:

Interdisciplinary team:
Table 68-1 Characteristics of Acute Kidney Injury and Chronic Kidney Disease:
Acute Kidney Injury:
Onset: Sudden (Hours-Days)

% of Nephron Involvement: 50-95%

Duration: May not progress; full recovery (return to baseline) possible
ESKD occurs in 10-20% with lifetime reliance on dialysis or kidney transplant

Prognosis: Good when kidney function is maintained or returns; High mortality associated with renal replacement therapy requirements of prolonged illness

Chronic Kidney Disease:
Onset: Gradual (Months-Years)

% of Nephron Involvement:
- Varies by stage; generally symptomatic with 75% loss and dialysis ith 90-95% loss

Duration: Progressive and permanent; Treatment and lifestyle can slow progression and delay onset of ESKD

Prognosis: Fatal without a renal replacement therapy (dialysis or transplantation); Reduced life span and potential for complex medical regimen even with optimal
5 D's of Managing Renal Failure:
1. Diet
2. Drugs
3. Dialysis or Donated Kidney
4. Discipline
5. Dying with Dignity
Hemodialysis:
Patient selection-Depend on the manifestation and glomerular filtration rate

Dialysis settings-Depending on the pt's needs

Procedure- technique in which substances move from the blood across a semipermeable membrane into a dialysis solution

Anticoagulation- Clotting can occur during dialysis
Subclavian Dialysis Catheters:
These catheters are radiopaque tubes that can be used for hemodialysis access.

The Y-shaped tubing allows arterial outflow and venous return through a single catheter.

A. Mahurkar catheter, made of polyurethane and used for short term access.

B. A PermCath catheter, made of silicone and used for long term access.
Hemodialysis Circuit:
Vascular Access:
Arteriovenous (AV) fistula or graft for long-term permanent access

Hemodialysis catheter, dual or triple lumen, or AV shunt for temporary access

Precautions- Assess for adequate circulation of the fistula or graft. Auscultate or palpate over site for bruit or a thrill.

Complications-Thrombosis, infections, stenosis

Vascular Access Complications:
- Thrombosis or stenosis
- Infection
- Aneurysm formation
- Ischemia
- Heart failure
Hemodialysis Nursing Care:
Drugs

Postdialysis assessment:
- Hypotension
- Headache
- Nausea, vomiting
- Malaise, dizziness
- Muscle cramps or bleeding
Complications of Hemodialysis:
- Dialysis disequilibrium syndrome

- Infectious disease

- Hepatitis B and C

- Human immunodeficiency virus (HIV)
Peritoneal Dialysis:
- Involves siliconized rubber catheter placed into abdominal cavity for infusion of dialysate

Types:
Continuous ambulatory (CAPD)- no machine is necessary.

Automated-Used in acute care and ambulatory settings.

Intermittent-Combines osmotic pressure gradients with true dialysis

Continuous-cycle- Uses an automated cycling machine. Exchanges occur at night when the pt is sleeping.
Continuous Ambulatory Peritoneal Dialysis (CAPD):
Automated Peritoneal Dialysis:
Complications of Peritoneal Dialysis:
- Peritonitis
- Pain
- Exit site/tunnel infections
- Poor dialysate flow
- Dialysate leakage
- Other complications
Nursing Care for Peritoneal Dialysis:
Before treatment: Evaluate baseline vital signs, weight, laboratory tests

Continually monitor patient for respiratory distress, pain, discomfort

Monitor prescribed dwell time, initiate outflow

Observe outflow amount and pattern of fluid
Kidney Transplantation :
Candidate selection criteria

Donors- living, non-heart beating, and cadaveric donors

Preoperative care- Pre-op exam, NPO, lab eg immunologic studies.
Immunologic studies

Surgical team-Surgeons, anesthesiologist, nurses

Operative procedure- Organ harvested, kidneys are removed and preserved until implantation
Postoperative Care for Kidney Transplantation:
Urologic management:

Assessment of hourly urine output × 48 hr:

Complications:
Rejection- Immunosuppressive Drug Therapy

- Acute tubular necrosis
- Thrombosis
- Renal artery stenosis
- Other complications
- Immunosuppressive drug therapy-Neoral (cyclosporine)
- Psychosocial preparation--
Educate patient and family members on treatment regimens.
Patient diagnosed with pre-renal kidney injury in most cases have a history of myocardial infarction
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A marathon runner hasn't urinated much in a few days and they have increased HR and Low BP- Give fluids/ bottle of water immediately
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Aspirin, Ibuprofen, Naporoxen can affect serum creatinine and BUN
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A patient with AKD and urine output of 2000ml/day the main concern should have regarding this patient is electrolyte and fluid imbalance
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A patient is receiving 1000ml of nss; patent develops SOB so the priority here is to slow down the infusion because it could be fluid overload
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If a patient has increased K, Creatinine, and Urine Output of 350ml/day with that the nurse must place the patient on a cardiac monitor because the K level affects the heart
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Patient with a central line catheter or hemodialysis the nurse must place a heparin and with or without saline after to flush the line
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A patient on continuous venal-venous hemofilration a BP of 76/58 is cause for immediate action
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Continuum of care is imperative to positive patient outcomes- Continuity of care is important to assess subtle differences in clients. Therefore, the registered nurse (RN) who was assigned to this client previously should again give care to this client.
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