AKI
What are the 3 causes of AKI (acute kidney injury)? Give patho and examples
PRERENAL- occurs before the kidney. Issues that cause decreased perfusion to the kidney such as hypovolemia, hypotension, hemorrhage, renal losses, MI, sepsis, anaphylaxis, burns( anything that causes volume depletion, impaired cardiac efficiency and vasodilation)
INTRARENAL- acute parenchymal damage to the glomeruli. ex. Nephrotoxic drugs- aminoglycosides, contrast dye, acute pyelonephritis, acute glomerulonephritis, NSAIDS, heavy metals ( Think:Drugs, Infection, Injury)
POSTRENAL-blockage in urinary system AFTER the kidney that prevents urine drainage out of the system- renal calculi, tumors, BPH, stricures, blood clots, neuro injury (stroke);bladder not emptying properly
Nursing interventions during OLIGURIC phase of AKI ( think interventions that have to do with the pathophysiology of the decreased ability of glomerulus to filter blood
* Low protein diet- unhealthy kidneys lose the ability to remove protein waste and it starts to build up in the blood
*Safety- Neuro status checks- toxins that are building up affect the brain and can cause confusion, delirium and even seizures
*Monitor EKG-(tall peaked T waves, wide QRS complex) increased serum potassium can affect cardiac function- Restrict K+ containing foods, may give kayexalate
* I&O- there will be increased fluid in the body so monitor daily weights, BP, lung sounds, assess for edema and hypertension
*monitor for metabolic acidosis- PH<7.5, confusion, Kussmaul respirations ( deep, rapid breathing to blow off C02 to increase blood PH)
*monitor for mild hyponatremia- increased phosphate and decreased calcium, high urine specific gravity >1.020
What are the 5 stages of CKD- give renal function and GFR
Stage 1- GFR>90 kidney damage with normal renal function but with proteinuria >3 months
Stage2 GFR 60-89 kidney damage with mild loss of renal function with proteinuria > 3 months
Stage 3 GFR 30-59 mild to severe loss of renal function
Stage 4 GFR 15-29 severe loss of renal function
Stage 5 GFR <15 END STAGE RENAL DISEASE
Hemodialysis- what does it do?
eliminates excess fluid, electrolytes, and waste products from the body. Used in patients with acute or chronic kidney disease. usually done 3 times a week
what is the difference between palliative and hospice care?
palliative originated in oncology as a way to improve quality of life. Does not mean patient is terminal.
Hospice is the care of the dying
Give the Four phases of AKI and explanation
INTIATION- begins with the initial insult and ends when oliguria develops
OLIGURIA- increase in uric acid, creatinine, urea,K+,Mg+, <400 ml/day urine. lasts 1-2 weeks
DIURESIS- gradual increase in urine output, glomerular filtration starting to recover, nephrons filtering the blood but CANT concentrate urine
RECOVERY- renal function improving, may take 3-12 months. Labs return to normal level
Signs and symptoms of hyperkalemia
ECG changes, irritability, abdominall cramping, diarrhea,paresthesia, generalized muscle weakness. muscle weakness may present as slurred speech, difficulty breathing, paresthesia, and paralysis.
expected lab values in late stage CKD ( early stages are asymptomatic)
INCREASED- BUN/creatinine, potassium, phospate, magnesium, fluid volume (hypervolemia)
DECREASED- calcium
proteinuria and hematuriawhen a patient has a fistula placed how long until it is "mature"?
major components of fistula assessment?2-3 months
auscultating for bruit, palpate for thrill ( the thrill is the mixing of blood)
which therapeutic communication technique can sometimes be the most helpful with a patient with a terminal illness
silence- Resist the impulse to fill the empty space in communication with talk
Give examples of medication dosages that need to be adjusted in a patient with AKI due to them being eliminated in the kidneys.
Are medication dosages made by actual weight or pre illness weight?
Antibiotics- especially aminoglycosides (gentamycin, tobramycin)
Digoxin (lanoxin)
Phenytoin (dilantin)
ACE inhibitors
magnesium containing agents
** actual weight-patient may lose 0.2-0.5kg (0.5-1lb) each day
nursing interventions for DIURESIS period( interventions related to the patient voiding 3-6 liters/day due to osmotic diuresis
Risk for- hypovolemia, dehydration, hyponatremia, hypotension, hypokalemia
monitor- strict I &O, daily weights, s&s dehydration, supplements, IV fluids
Why is calcium low in CKD?
what do we give to regulate this?
INCREASED phosphorous levels trigger the parathyroid glad to release PTH, this stimulates the bones to release calcium to increase blood calcium. calcium binds to the phoshorous to compensate for elevated serum phosphorous( kidneys activate vit. D which helps the body reabsorb Ca+ from food)
phosphate binders are given ex-calcium carbonate, calcium acetate (phoslo) binds to phosphorous in food and is excreted in stool- Give with meals!
major risks with peritoneal dialysis? Interventions?
Infection!! sterile precautions should be maintained, monitor color of outflow, should be clear, light yellow. Bloody, cloudy outflow indicates possible infection.
*Poor outflow/inflow- check for kinks in tubing, address constipation, reposition patient, milk tubing to break up clots
Protein loss- increase protein in diet
hyperglycemia- administer insulin as needed
signs that death may be imminent
pt withdraws, sleeps more
increased interval between respirations, weakened and irregular pulse, diminished BP
skin color changes (mottling; blood is being shunted away from limbs to the critical organs)
is AKI reversible? What happens after 3 months?
yes, it becomes chronic renal failure
Nursing interventions for heat stroke
Cool- cool sheets, towels, ice to neck, groin, chest, axillae, cooling blanket, immerse in cold water bath
Monitor- temp, VS, ECG, CVP, LOC, I&O
IV fluids
may need anticonvulsant, potassium, sodium bicarbonate, benzos
two most common causes of CKD and why?
Diabetes Mellitus- uncontrolled hyperglycemia causes glucose to stick to artery walls which causes damage to the arteries that supply blood to the kidneys
Hypertension-uncontrolled HTN= high pressure on artery wall to kidney becomes damaged=less blood to nephrons
signs and symptoms of heat stroke
CNS dysfunction (confusion), elevated temp of 105 or higher, hot, dry skin, anhydrosis, signs of shock (tachypnea, hypotension, tachycardia)
signs of fluid volume overload
tachycardia, tachypnea, HTN, bounding pulses, weight gain, edema, ascites, dyspnea, crackles, JVD
decreased HCT and HGB, serum osmolality, urine osmolarity, specific gravity, BUN
how long does it take to recover from AKI
can take a year or more, some patients never recover and develop CKD
nursing interventions for hypothermia
remove wet clothes
Rewarm- Active:bypass, warm IV fluids, warm 02, warm peritoneal lavage
Passive: warm blankets, bed heaters
what are some major symptoms that could arise due to uremia (increased waste build up in the blood)?
Itching- deposits of urea crystals on the skin via sweat glands, looks like frost "uremic frost"
Confusion
metabolic acidosis- kussmauls respirations
when re warming a patient what is a major complication that can cause cardiac dysrythmias?
Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac and electrolyte disturbances
after a chest tube is removed what kind of dressing does the nurse apply
sterile petroleum jelly gauze tape on 4 sides