NURS 460 - Renal (Exam 2) (haley_huff4)

What are the three origins of an AKI?

Pre-renal, intra-renal, post-renal

What is an AKI?

Abrupt increase in creatinine resulting in an injury or insult that causes a functional or structural change in the kidney

What are the three main results of an AKI?

Increased BUN, creatinine, and urine electrolytes

What is normal GFR?

125 mL/min

What are the 4 main functions of the kidney?

Regulation of fluid electrolyte and acid base balance
Erythropoietin production
Regulation of blood pressure via RAAS
Vitamin D production

What is the most common origin of AKI?

Pre-renal

What causes a pre-renal AKI?

Caused by decreased renal blood flow or obstruction of the renal artery

What can decrease CO and lead to AKI?

Severe HoTN, hypovolemia, vasoconstriction

What happens to the function and structure of nephrons and glomeruli in AKI?

Normal

What are the two main ways to maintain BP and treat pre-renal AKI?

Improve CO, relieve renal artery obstruction

What are ways to improve CO with pre-renal AKI?

Normal saline until CVP \= 12, assess VS/UO/CVP/PAWP, MAP of 65+, NE for BP support

What kind of AKI is caused by decreased CO?

Prerenal

What are the two main ways to restore renal perfusion in prerenal AKI?

Angioplasty, stent

What are intra-renal causes of AKI?

Abdominal CS, cytotoxic agents, sepsis, prolonged hypoperfusion of the kidneys, basement membrane of the renal tubules are damaged, rhabodomyelosis

What kind of meds should be avoided to prevent further kidney injury with an AKI?

Nephrotoxic

What is important to do when administering nephrotoxic drugs with an AKI?

Monitor peak and trough levels closely

If a patient has an AKI, what should be done if contrast is necessary?

Give prophylactic acetylcysteine

What are the four phases of an intrinsic AKI?

Onset, oliguric/non-oliguric, diuretic, recovery

What are examples of post-renal causes of AKI?

Obstruction of urinary outflow, BPH, tubular obstruction from crystals, ureteral obstruction, prostatic cancer

How does post-renal AKI resolve?

Remove obstruction

What happens to BUN and creatinine with age?

Increase

How is asymptomatic dilutional hyponatremia treated?

Fluid restriction

How is symptomatic dilutional hyponatremia treated?

Diuretics and saline infusion if fluid restriction is ineffective

What are manifestations of a sodium level of 125-135?

None

What are manifestations of a sodium level of 111-124?

HA, lethargy, disorientation

What are manifestations of a sodium level of 100-110?

Confusion, N/V, lethargy, violence

What are manifestations of a sodium level below 100?

Delirium, convulsions, coma, C-S breathing

What hyponatremia level is asymptomatic?

\>125

What are ways to treat hyperkalemia?

Increase K+ excretion, IV calcium, shift potassium back into cells, kayexalate, dialysis

Which patients should NOT receive IV calcium to treat hyperK+?

Patients taking digitalis

What potassium level could cause death?

\>7.0

What is hypocalcemia defined by?

Ionized calcium less than 4.25 or serum calcium less than 8.5

How is mild hypocalcemia treated?

Oral replacement

What is the main manifestation of mild hypocalcemia?

Numbness/tingling

How is severe hypocalcemia treated?

IV replacement

What is the main manifestation of severe hypocalcemia?

Chvostek's and Trousseau's

What is hyperphosphatemia defined as?

Serum level greater than 4.5

How is hyperphosphatemia treated?

Adequate hydration, dietary phosphate restriction, calcium supplementation, administration of phosphate binders

Which electrolyte has an inverse relationship with phosphate and can be used to treat hyperphosphatemia?

Calcium

What are the most common electrolyte imbalances with AKI?

Hyponatremia, hyperkalemia, hypocalcemia, hyperphosphatemia

What is pH with metabolic acidosis?

What is bicarb with metabolic acidosis?

At what point is bicarb administered for metabolic acidosis?

When bicarb is

What is a healthy albumin range?

3.5-4.0

What is a healthy total protein range?

6-8

What are indications for RRT?

Oliguria with fluid volume overload
Hyperkalema (\>6.5)
Hyponatremia (

What are the three types of RRT?

Hemodialysis, CRRT, peritoneal

How long does hemodialysis last?

3-4 hour sessions

What are indications for hemodialysis?

Severe fluid overload or electrolyte imbalances
Acute or chronic renal failure
Drug OD or poisonings
Transfusion reactions

How long does CRRT last?

Over 24 hours

When is CRRT used?

When hemodynamically unstable, it's softer on the patient, removes 3-4 L in 24 hours

Which type of RRT is used for hemodynamically unstable patients?

CRRT

How often is peritoneal dialysis done?

Every 4 hours

What is the purpose of peritoneal dialysis?

Gradual restoration of fluid volume and electrolyte balance

What are the advantages of hemodialysis?

Rapidly corrects electrolyte imbalances, restores fluid balance, adjusts acid-base balance

What is determined before doing hemodialysis?

Amount of fluid overload by subtracting "dry weight" from the current weight

What does nursing management consist of before patients undergo hemodialysis?

Assess measures of fluid balance, hold certain meds prior to dialysis, check patient's temp, manage BP

What does nursing management consist of after patients undergo hemodialysis?

Obtain weight after dialysis, assess access site, administer meds held before dialysis, review lab results

What does nursing management consist of before patients undergo CRRT?

Assess volume status, clarify fluid balance goal with a nephrologist, obtain pre-procedural labs

What should a nurse do with the equipment before starting CRRT?

Prime all circuit lines and expel air, maintain sterile technique

What should be done during CRRT?

Assess ultra-filtration rate hourly, administer replacement fluid if necessary, determine hourly fluid needs and titrate, maintain patency, maintain heparin infusion, review clotting studies, assess hemofilter for signs of clotting

Which dialysis method is NOT preferred for AKI patients?

Peritoneal

What are the disadvantages of peritoneal dialysis for AKI patients?

Treatment occurs slowly, dysfunction progresses quickly, ineffective for removal of urea, "dwell" fluid impairs respiratory function, risk for peritonitis

How can a nurse monitor for AKI recovery?

Monitor for diuretic phase, BUN and creatinine levels, fluid volume, electrolytes (esp Na and K), avoid renal toxins

What are the four main purposes of the kidneys?

Fluid volume status, acid/base, electrolyte balance, clear body of nitrogenous waste

What is normal BUN?

5-25

What is normal creatinine?

0.5-1.5

What might be administered during dialysis to help with blood counts?

EPO

What happens to GFR in pre-renal AKI?

Decreased

What are causes of pre-renal AKI?

Blood loss, volume loss, sepsis, severe vasoconstriction

How is pre-renal AKI treated?

Restoring volume or opening up blockage to kidneys

How high might CVP get to permissibly when treating pre-renal AKI?

12

How might BP be supported in pre-renal AKI?

Levofed

What should be done before giving Levofed for pre-renal AKI?

Give volume

What is the most common cause of intra-renal AKI?

Pre-renal AKI (prolonged hypoperfusion)

What are other terms for intra-renal AKI?

Intrinsic, ATN

Why might acetylcysteine be given with contrast procedures?

Binds to contrast, prevents buildup due to renal insufficiency

What happens in the onset phase of an intrinsic AKI?

BUN and creatinine start to increase, UO decreases by 20%

How much urine is produced in the oliguric phase?

What happens during the oliguric phase?

Patient retains fluid and cannot maintain electrolytes or acid-base balance, cannot excrete enough nitrogenous waste, ischemic injury to epithelial cells

Does every patient go through the oliguric stage?

No; some are non-oliguric and urinate adequately

Which is more dangerous - oliguric or non-oliguric? Why?

Non; often don't realize there's an issue

What happens during the diuretic phase?

UO increases up to 5 L/day, still electrolyte and acid-base issues, BUN and creat start to trend down

How long is the recovery phase?

6-12 months

What is the first sign of post-renal AKI?

Anuria

Is dilutional hypoNa+ treated with a higher salt diet? Why or why not?

No; water follows salt and will further increase fluid

What is the purpose of giving diuretics with a saline infusion in dilutional hypoNa+?

Gets rid of water while holding onto Na+

Which electrolyte imbalances most commonly occur in AKI?

Dilutional hypoNa+, hyperkalemia, hypocalcemia, hyperphosphatemia

How is potassium excretion promoted?

Lasix

What are ways to promote potassium intake into the cells?

Calcium gluconate, bicarb, insulin, glucose,

If a patient with hyperkalemia has not had dialysis before, what should be done?

C BIG, then dialysis

Which meds can be given for hyperphosphatemia? Why?

Calcium carbonate or citrate (inverse relationship), Renegel (absorbs phosphate)

Which acid-base imbalance occurs in AKI?

Metabolic acidosis

What are s/sx of metabolic acidosis?

Altered mentition, hyperactive reflexes, tingling, tetany, seizures, dysrhythmias

Why might patients with AKI be thirsty?

Fluid restriction

Why might patients with AKI experience pruritis?

Buildup of urea on skin

What are symptoms of uremia?

Mental changes, neuropathy or pericarditis

Which type of dialysis is most commonly used in the ICU?

CRRT

What is the difference between hemodialysis and CRRT?

Same mechanism; CRRT is over 24 hours

What is assessed hourly when patients are on CRRT?

I&O