Rapid and Short
1. Urine output less than 1000 mL for the past 24 hours.
2. Urine output less than 800 mL for the past 24 hours.
3. Urine output less than 600 mL for the past 24 hours.
4. Urine output less than 400 mL for the past 24 hours.
The most common initial manifestation of ARF is oliguria, a reduction to urine output to less than 400 mL/day.
1. Progressive irreversible destruction of the kidneys
2. A rapid decrease in urinary output with an elevated BUN level
3. Decreasing creatinine clearance and urinary output
4. Prostration, somnolence, and confusion with coma and imminent death
CKD involves progressive, irreversible loss of kidney function.
1. Urinalysis
2. Serum creatinine and blood urea nitrogen
3. A 24-hour urine creatinine clearance
4. Bladder ultrasound
Because creatinine is an endogenous waste product that is filtered at the glomerulus, passed through the tubules, and excreted in the urine, creatinine clearance is a good measure of the GFR. To calculate the creatinine clearance, urine is collected for 24 hours. The serum creatinine level is measured midway through the collection. Then the creatinine clearance is calculated using the formula: volume of urine in mL/min times the urine creatinine in mL/dL divided by the serum creatinine in mg/dL. The normal adult GFR ranges from 125 mL/min to 200 mL/min. A decreased GFR is associated with renal dysfunction and increases the risk of adverse cardiovascular events. A urinalysis examines the urine for color, clarity, odor, pH, and specific gravity; tests for protein, glucose, ketones, and other substances; and microscopically examines the cells. The creatinine and BUN measure the endogenous waste products in the blood. A bladder ultrasound is used to measure the amount of urine in the bladder.
1. Check the sodium level.
2. Place the client on a cardiac monitor.
3. Encourage increased vegetables in the diet.
4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration
The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Fluid intake is not increased because if contributes to fluid overload and would not affect the serum potassium in the diet, and their use would not be increased. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse.
1. No medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins.
2. The diet is less restricted and dialysis can be performed at home.
3. The dialysate is biocompatible and causes no long-term consequences.
4. High glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss.
Advantages of peritoneal dialysis include fewer dietary restrictions and home dialysis is possible.
1. Primary cause of death is infection.
2. It usually affects older people.
3. The disease course is potentially reversible.
4. The most common cause is diabetic nephropathy.
5. Cardiovascular disease is the most common cause of death.
3. The disease course is potentially reversible.
ARF is potentially reversible. It has a high mortality rate, and the primary cause of death is infection; the primary cause of death for chronic kidney failure is cardiovascular disease. The most common cause of ARF is acute tubular necrosis; the most common cause of CKD is diabetic nephropathy. ARF commonly follows severe, prolonged hypotension or hypovolemia or exposure to a nephrotoxic agent. ARF is seen mostly in healthy people with normal kidney function.
1. Older African Americans
2. Individuals older than 60 years
3. Those with a history of pancreatitis
4. Those with a history of hypertension
5. Those with a history of type 2 diabetes
2. Individuals older than 60 years
4. Those with a history of hypertension
5. Those with a history of type 2 diabetes
Risk factors for CKD include diabetes mellitus, hypertension, age older than 60 years, cardiovascular disease, family history of CKD, exposure to nephrotoxic drugs, and ethnic minorities (e.g., African American, Native American).
1. Potassium level of 5.9 mEq/L
2. BUN level of 25 mg/dL
3. Sodium level of 144 mEq/L
4. pH of 7.5
Hyperkalemia is one of the most serious complications in ARF because it can cause life-threatening cardiac dysrhythmias.
1. Weigh patient three times weekly
2. Increase dietary sodium and potassium
3. Provide a low-protein, high-carbohydrate diet
4. Restrict fluids according to the previous day's fluid loss
Patients in the oliguric phase of acute Renal Failure have fluid volume excess with potassium and sodium retention. They will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 mL for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times per week.
1. "It is essential that you maintain aseptic technique to prevent peritonitis."
2. "You will be allowed a more liberal protein diet after you complete CAPD."
3. "It is important for you to maintain a daily written record of blood pressure and weight."
4. "You must continue regular medical and nursing follow-up visits while performing CAPD."
Peritonitis is a potentially fatal complication of peritoneal dialysis, and it is imperative to teach the patient methods to prevent it from occurring. Although the other teaching statements are accurate, they do not address the potential for mortality by peritonitis, making that nursing action the highest priority.
1. The patient is hypovolemic because of hemorrhage.
2. The patient relates a history of chronic urinary tract obstruction.
3. The patient has vascular changes related to coagulopathies.
4. The patient is receiving antibiotics such as gentamicin.
Prerenal causes of ARF are factors external to the kidneys. These factors reduce systemic circulation, causing a reduction in renal blood flow, and they lead to decreased glomerular perfusion and filtration of the kidneys.
1. Insert a saline lock
2. Obtain a daily weight
3. Provide a high-protein diet
4. Administer calcium carbonate with each meal
With CKD, the nurse is concerned about fluid volume overload and accumulation of waste products. Infusing an intravenous (IV) solution into a client with renal failure significantly increases the risk for overload. If an IV access is needed, it usually involves only a saline lock. Obtaining the client’s daily weight is one of the most important assessment tools for evaluation changes in fluid volume. The kidneys also are responsible for removing waste products. When a client experiences kidney failure, the blood urea nitrogen (BUN) and serum creatinine levels rise. BUN and creatinine are the byproducts of protein metabolism, so monitoring of protein intake is important. Clients with CKD will have protein restricted early in the disease to preserve kidney function. In end-stage disease, protein is restricted according to the client’s weight, the type of dialysis, and protein loss. The client also experiences increased potassium, increased phosphates, and a decreased calcium. The client receives phosphate binders, calcium supplements, and vitamin D to prevent bone demineralization (osteodystrophy) from chronically elevated phosphate levels.
1. Specific gravity of urine at 3 different times is 1.010.
2. The serum creatinine level is normal.
3. The blood urea nitrogen (BUN) level is normal or below.
4. Hypokalemia is identified.
A urinalysis may show casts, red blood cells (RBCs), white blood cells (WBCs), a specific gravity fixed at about 1.010, and urine osmolality at about 300 mOsm/kg.
1. Decrease in serum creatinine levels (SCr)
2. Increase in white blood cells (WBCs)
3. Increase in serum hematocrit (Hct)
4. Decrease in blood pressure (BP)
Epoetin alfa (Epogen) stimulates red blood cell production and increases Hct levels. Initial effects should be seen in 1 to 2 weeks, and normal Hct levels should be achieved within 2 to 3 months. Epoetin alfa (Epogen) does not have a direct effect on SCr levels. Elevated WBCs could indicate the client has an infection. Epoetin alfa (Epogen) does not affect WBCs. As the Hct rises, there can a transient increase in BP.
1. Irrigate the graft daily with low-dose heparin.
2. Monitor for any increase in blood pressure in the affected arm.
3. Listen with a stethoscope over the graft for presence of a bruit.
4. Frequently monitor the pulses and neurovascular status distal to the graft.
A thrill can be felt by palpating the area of anastomosis of the arteriovenous graft, and a bruit can be heard with a stethoscope. The bruit and thrill are created by arterial blood rushing into the vein.
1. Prerenal
2. Intrarenal
3. Postrenal
4. Extrarenal
Serum myoglobin levels increase in crush injuries when large amounts of myoglobin and hemoglobin are released from damaged muscle and blood cells. The accumulation may cause acute tubular necrosis, an intrarenal cause of renal failure. Prerenal causes are conditions that interfere with the perfusion of blood to the kidney. Postrenal causes include conditions that cause urinary obstruction distal to the kidney. The cause and type of renal failure may determine the interventions used in treatment.
1. Glycosuria
2. Polyphagia
3. Blood pressure 98/58 mm Hg
4. Crackles auscultated in lungs
CRF is a condition in which the kidneys have progressive problems in clearing nitrogenous waste products and controlling fluid and electrolyte balance within the body. The typical signs and symptoms of CRF include proteinuria or hematuria, not glycosuria. The nurse would observe anorexia and nausea in this client, not polyphagia. Cardiovascular symptoms of heart failure and hypertension are caused by the fluid volume overload resulting from kidney’s inability to excrete water. The signs and symptoms of heart failure include jugular venous distention, S3 heart sound, pedal edema, increased weight, shortness of breath, and crackles auscultated in lungs.
1. Hyperkalemia and hyponatremia
2. Hyperkalemia and hypernatremia
3. Hypokalemia and hyponatremia
4. Hypokalemia and hypernatremia
In the diuretic phase of ARF, the kidneys have recovered their ability to excrete wastes but not to concentrate the urine. Hypovolemia and hypotension can result from massive fluid losses. Because of the large losses of fluid and electrolytes, the patient must be monitored for hyponatremia, hypokalemia, and dehydration.
1. Careful monitoring of intake and output.
2. Daily patient weights.
3. Meticulous aseptic technique.
4. Increase intake of vitamin A and D.
5. Frequent mouth care.
2. Daily patient weights.
3. Meticulous aseptic technique.
5. Frequent mouth care.
You have an important role in managing fluid and electrolyte balance during the oliguric and diuretic phases of ARF. Observing and recording accurate intake and output are essential. Measure daily weights with the same scale at the same time each day to assess excessive gains or losses of body fluids. Mouth care is important to prevent stomatitis, which develops when ammonia (produced by bacterial breakdown of urea) in saliva irritates the mucous membrane.
1. Encourage fluids.
2. Notify the physician.
3. Continue to monitor vital signs.
4. Monitor the site of the shunt for infection.
The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood ample would be obtained as prescribed for culture and sensitivity determinations.
1. Hypotension.
2. Electrocardiographic (ECG) changes.
3. Hypernatremia.
4. Pulmonary edema.
5. Urine with high specific gravity.
4. Pulmonary edema.
When urinary output decreases, fluid retention occurs. You monitor the patient in the oliguric phase of ARF for hypertension and pulmonary edema. The patient is monitored for hyponatremia. Damaged tubules cannot conserve sodium, and the urinary excretion of sodium may increase, resulting in normal or below-normal levels of serum sodium. Monitor for ECG changes and hyperkalemia. Initially, clinical signs of hyperkalemia are apparent on electrocardiogram, which demonstrate peaked T waves, widening of the QRS complex, and ST-segment depression. Urinary specific gravity is fixed at about 1.010.
1. Hypertension.
2. Vascular calcifications.
3. A genetic predisposition.
4. Hyperinsulinemia causing dyslipidemia.
5. Increased high-density lipoproteins levels.
2. Vascular calcifications.
4. Hyperinsulinemia causing dyslipidemia.
Traditional cardiovascular risk factors, such as hypertension and elevated lipid levels, are common in CKD patients. Hyperinsulinemia stimulates hepatic production of triglycerides. Most patients with uremia develop dyslipidemia. Much of the cardiovascular disease may be related to nontraditional risk factors such as vascular calcification and arterial stiffness. Vascular calcification and arterial stiffness are major contributors to cardiovascular disease in CKD. Calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial and incompletely understood, but they include (1) vascular smooth muscle cells that change into a chondrocyte or osteoblast-like cell, (2) high total body calcium and phosphate levels due to abnormal bone metabolism, (3) impaired renal excretion, and (4) drug therapies to treat the bone disease (e.g., calcium phosphate binders).
1. Urinalysis, hematocrit, hemoglobin
2. Culture and sensitivity testing, serum sodium
3. Urine specific gravity, intravenous pyelogram
4. Fasting blood glucose, serum potassium, serum calcium
Because of the potentially life-threatening outcomes associated with hyperglycemia, hyperkalemia, and hypocalcemia, they are the most relevant to nursing management of the client with CKD. The diagnostic tests in options 1, 2, and 3 may be helpful in diagnosing renal failure or in monitoring treatment but are not the most relevant. Additionally, decreased hematocrit and hemoglobin occur in CKD because of the decreased level or erythropoietin. However, a decrease in hematocrit and hemoglobin may be reflective of various health alterations.
1. Decreased fluid intake, carbohydrate intake, and protein intake.
2. Increased fluid intake; decreased carbohydrate intake and protein intake.
3. Decreased fluid intake and protein intake; increased carbohydrate intake.
4. Decreased fluid intake and carbohydrate intake; increased protein intake.
Water and any other fluids are not routinely restricted in the pre-end-stage renal disease (ESRD) stages. Patients on hemodialysis have a more restricted diet than patients receiving peritoneal dialysis. For those receiving hemodialysis, as their urinary output diminishes, fluid restrictions are enhanced. Intake depends on the daily urine output. Generally, 600 mL (from insensible loss) plus an amount equal to the previous day's urine output is allowed for a patient receiving hemodialysis. Patients are advised to limit fluid intake so that weight gains are no more than 1 to 3 kg between dialyses (interdialytic weight gain). For the patient who is undergoing dialysis, protein is not routinely restricted. The beneficial role of protein restriction in CKD stages 1 through 4 as a means to reduce the decline in kidney function is being studied. Historically, dietary counseling often encouraged restriction of protein for CKD patients. Although there is some evidence that protein restriction has benefits, many patients find these diets difficult to adhere to. For CKD stages 1 through 4, many clinicians encourage a diet with normal protein intake. However, you should teach patients to avoid high-protein diets and supplements because they may overstress the diseased kidneys.
1. Stop the dialysis
2. Slow the infusion
3. Decrease the amount to be infused
4. Explain that the pain will subside after the first few exchanges
Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should be decreased, and the infusion should not be slowed or stopped.