need to know
Antibiotics –Aminoglycosides (gentamicin, tobramycin) –Tetracyclines –Amphotericin B (Antifungal)
• Heavy metals (lead, mercury, cadmium, gold)
• Poisons (insecticides)
• Contrast dyes
•Analgesics (Salicylates, acetaminophen, NSAIDS)
What are nephrotoxins?
Rapid, acute disease process; usually reversible if addressed in a timely manner. If not quickly addressed CKD is inevitable
due to injury to kidney
What is acute kidney injury?
AKI
Serum creatinine gradually increases (1-2 mg/dL every 24-48 hrs.) • BUN - can increase to 80-100mg/dL within 1 week • Urine specific gravity – can be elevated up to 1.030 in pre-renal or diluted as low as 1.000 in intra-renal • Serum electrolytes – Na+ decreased (pre) or increased (intra), hyperkalemia, hyperphosphatemia, hypocalcemia • Hematocrit decreased • Urinalysis – presence of sediment (RBC’s, casts) • Metabolic acidosis
What is the laboratory studies and results?
Urinary System – urine contains protein, blood particles, change in amount, color, concentration
Metabolic Disturbances – waste product accumulation, altered carbohydrate metabolism, elevated triglycerides
Electrolyte and Acid-Base Disturbances – Potassium – high, can lead to dysrhythmias – Sodium – hypo in early & hyper in later stages – Calcium low and Phosphate high –Magnesium – high –Metabolic acidosis – kidneys inability to excrete acid (usually ammonia) as more nephrons are lost
Musculoskeletal System – osteodystrophy –Thin fragile bones from low Ca+/high phosphorus
• Integumentary System –Uremic frost, yellow discoloration to skin, itching, dry, scaly skin
• Reproductive System –Decreased estrogen, progesterone, infertility, amenorrhea –Erectile Dysfunction
What are clinical manifestations of CKD?
• Renal osteodystrophy (Mineral Bone Disorder) – Phosphate binders
• Anemia – Erythropoietin (Epoetin alfa) – stimulates production of RBC’s – Ferrous sulfate – to prevent severe iron deficiency
• Dyslipidemia – Statin drugs to lower LDL – Fibric Acid Derivatives to lower triglycerides
• Hypocalcemia –Vit D & calcium supplements
What is medical management for CKD?
(hours to days) Triggering event through oliguria development
*onset
What is initiating phase (onset) for AKI clinical phases?
Hypovolemia • Hypotension • Vasoconstriction • Decreased cardiac output • Shock • Heart failure • Myocardial infarction • Dehydration • Diuretic overuse • Hemorrhage • Antihypertensives • Sepsis • Arterial embolism • Thrombus
results from decrease blood flow to kidney -- hypoperfusion
What are causes of prerenal AKI?
-most common
Cardiovascular - Fluid overload (dependent & generalized edema), heart failure, JVD, hypertension, possible Dysrhythmias (hyperkalemia) • Respiratory – pulmonary edema, crackles, decreased oxygenation, SOB • Renal – scant to normal UOP depending on the phase • Neurological – confused, lethargic, muscle twitching, seizures • Integumentary – dry skin & mucous membranes
What are clinical manifestations of AKI?
Acute Kidney Injury
• Smoking • Diabetes Mellitus *
Chronic glomerulonephritis • Nephrotoxic medications (Gentamicin, NSAIDs)
• Hypertension, especially in African Americans *
• Autoimmune disorders (lupus) • Polycystic kidney disease • Pyelonephrosis • Renal artery stenosis
• Hyperlipidemia • Use of recreational drugs & NSAID’s • Obesity • Recurrent severe infections
• Respiratory System - –Uremic halitosis, SOB, tachypnea, pulmonary edema, Kussmaul respirations, crackles, pleural friction rub, frothy pink sputum Gastrointestinal System - Mucosal inflammation – Ulcers in mouth & throat, foul breath, blood in stool, anorexia, N&V
Neurologic System - CNS depression, AMS –Anxiety, depression, HA, lethargy, fatigue, decreased attention span, slurred speech, tremors, jerky movements, ataxia, seizures, coma
What are risk factors for CKD?
Protein restriction – unless on dialysis & they need more protein – Vitamin & mineral supplements
• Fluid restriction – Based on urinary output & body weight
• Sodium and Potassium restriction – Based on renal function
• Phosphate restriction – to avoid osteodystrophy – Limit intake to less than 1,000 mg/day
• Diet high in carbohydrates and moderate in fat
What is nutrition therapy for CKD?
(1 – 3 weeks) reduction in GFR – Urinary changes – urine output < 400 mL/day – Urine specific gravity between 1.007-1.010 – Fluid volume overload – Metabolic acidosis – High sodium concentration in urine – Increased BUN & Creatinine – Hyperkalemia & hyponatremia – Neurologic & Hematologic disorders
What is oliguric phase in AKI clinical phases?
Anticholinergic drugs • Autonomic nerve dysfunction • Infection • Trauma • Tumor • Calculi • Inflammation • Retroperitoneal fibrosis • Retroperitoneal hemorrhage • Accidental ligation (surgery) • Tumor • Uric acid crystals • Prostatic hyperplasia • Strictures
What are causes of postrenal AKI?
least common
• X-ray of pelvis, kidneys, ureters, bladder (KUB) • Kidney Ultrasound • CT scan • Kidney biopsy
What are diagnostic studies for AKI?
– Hematuria, proteinuria & decrease in specific gravity
– Gradual increase in serum creatinine over months to years • Can increase to 15 to 30 mg/dL
– Gradual increase in BUN with elevated serum creatinine • May reach 180-200 mg/dL
– Decreased creatinine clearance
– Decreased Hgb & Hct from anemia secondary to loss of erythropoietin
What is lab test for CKD?
-Neurological weakness/ fatigue/ confusion
-Cardiovascular increased BP and CVP, pitting edema, pericarditis
-Pulmonary SOB, depressed cough, thick sputum
-GI ammonia odor to breath, metallic taste, anorexia, N/V
-Skin dry flaky, purpura, yellow-gray kin color, pruritus
-Hematological anemia, increase serum K, bleeding tendencies
-Musculoskeletal cramps, bone pain, renal osteodystrophy
-Psychological withdrawal, behavior changes, depression
What is ESRD (end stage renal disease) manifestations in CRF?
* < 15 ml/min GFR
(1-3 weeks [2 to 6 weeks per ATI]) –Kidneys begin to recover –Urine output can increase from 1-3 L to 3-5 L per day –May lead to dehydration & electrolyte imbalances (Na & K) –BUN & Creatinine levels begin to normalize
What is diuretic phase for AKI clinical phases?
Acute Tubular Necrosis • Poorly treated prerenal failure • Nephrotoxins • Heavy metal poisoning (Lead) • Contrast dye • Trauma • Acute glomerulonephritis • Pyelonephritis • Renal vein thrombosis • Nephrosclerosis • Renal carcinoma • Sickle cell disease • Systemic lupus erythematosus • Vasculitis • Blood transfusion reaction • Intratubular obstruction (Tumor lysis, rhabdomyolysis)
What are causes of intrarenal AKI?
Anemia - decreased Erythropoietin
• Bleeding - Platelet dysfunction
•Infection -WBCs are altered → immunodeficiency and increase susceptibility to systemic and local infections
•Infection is the major cause of death in AKI
What is hematologic disorders: AKI?
• Hematologic System –Anemia – decreased production of erythropoietin –Bleeding tendencies – impaired platelet function (petechiae, ecchymoses, melena) –Infection – altered immune response
• Cardiovascular System –Fluid overload, HTN, hyperlipidemia, jugular distention, edema, dysrhythmias, heart failure, orthostatic hypotension, peaked T waves on EKG (hyperkalemia)
What are clinical manifestations of CKD?
-Evaluate access site for: patency and signs of infection, do not take BP or obtain blood samples from extremity that has access site
What is hemodialysis nursing actions for CRF?
(up to 12 months) –GFR increases up to 70-80% of normal –BUN/Creatinine decreases & fluid/electrolytes normalize
What is recovery phase for AKI clinical phases?
Develops more slowly than AKI; can occur over months to years. Is not reversible.
two biggest risk factors are uncontrollable diabetes and hypertension.
What is chronic kidney disease?
CKD
Drink at least 2 liters daily. (Consult with provider regarding prescribed fluid restrictions if needed) •Stop smoking •Limit alcohol intake •Maintain a healthy weight (diet and exercise) •Use NSAIDS and other prescribed medications cautiously •Control diabetes and hypertension to prevent complications (test for albumin in the urine yearly) •Take all antibiotics prescribed for infections
What is keeping kidneys healthy?
• Drug Therapy – Hyperkalemia – most serious complication • IV Regular Insulin • Sodium Bicarbonate • Kayexalate (Sodium polystyrene) • Calcium Gluconate
– Hypertension • Antihypertensives – Diuretics, Ca+ channel blockers for non-diabetics; ACE inhibitors & ARB’s for diabetics
What is medical management for CKD?
Fluid Management – monitor VS, I&O, daily weight, hydration status • Monitor for pulmonary edema - SOB, crackles, use oxygen, loop diuretics, High-Fowler’s position, • Maintain acid-base balance – peritoneal dialysis or hemodialysis • Monitor lab values – BUN, serum creatinine, creatinine clearance, CBC, electrolytes • Cardiac monitor – assess for EKG changes • Monitor cardiac output – assess for heart failure, use ACE’s, beta blockers • Enhance nutrition – calories, protein, fluid, K+, Na+, Phosphorus restrictions • Meticulous skin care, inspect vascular access devices, dialysis catheters • Psychosocial integrity - lifestyle disruptions, support groups
What is nursing care for CKD/ ESRD?