AC3 EXAM 3

What is AKI?

Acute kidney injury; rapid, but reversible loss of kidney function (hours to days)

What causes AKI?

Sepsis

Critical illness

Circulatory shock

Burns

Trauma

Cardiac surgery (especially with CPB)

Major noncardiac surgery

Nephrotoxic drugs

Radiocontrast agents

Poisonous plants and animals

Dehydration or volume depletion

Advanced age

Female gender

Black race

CKD

Chronic diseases (heart, lung, liver)

Diabetes mellitus

Cancer

Anemia

Manifestations of AKI

AMS, flank pain, fluid retention, poor fluid output

s/s of AKI

AKI levels/parameters

-Increase in SCr by ⩾0.3 mg/dl (⩾26.5 μmol/l) within 48 hours; or

- Increase in SCr to ⩾1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or

- Urine volume

AKI Cause: Prerenal

Sudden or severe drop in BP (shock), or interruption of blood flow to the kidneys

Dehydration, low blood pressure, heart failure

AKI Cause: Intrarenal

Direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply

Kidney damage (infection, injury, medications)

AKI Cause: Postrenal

Sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor, injury

Blocked urine flow (kidney stones, tumors)

Management of AKI

Treat underlying cause, rehydrate, investigate, stop nephrotoxic drugs, escalate and observe.

Assessment of AKI

Strict Is/Os

Daily Weights

Report urinary outpit if < 0.5 mL/kg/hr x 2+ hours

Oliguria (UO < 400 mL/day)

Azotemia: Build-up of Wastes in the Blood (Increased Blood Osmolarity, Creatinine, & BUN)

Laboratory Assessments

Creatinine: Waste Material from Muscle

Breakdown Cleared in Urine = Creatinine Clearance

Increased Serum Creatinine, Decreased Creatinine Clearance

Increased BUN

Monitor Electrolytes (potassium)

Varies Depending on Progression of Disease:

Osmolarity: Urine Osmolarity Low or Normal Depending

Serum Osmolarity Elevated in Volume-Depleted States Otherwise Normal

Specific Gravity: High or Low, it Depends

GFR: Decreasing (more to diagnose CKD, not AKI)

AKI Treatment

-diuretics

-antihypertensives

-dialysis: clear out metabolic waste

-fluids and electrolytes

-nutrition

-may need low sodium, potassium, phophorous diet

- Maintain regular BP

- Maintain Normal Fluid Status

- AVOID Nephrotoxic Drugs/Agents

- If Unavoidable, Monitor Drug Levels & Adjust Dosing

- Check Kidney Function Prior to Contrast

- Is/O's, Daily Weights, Monitor Electrolytes

- FVE: Diuretics

- IVF: Hypovolemia Suspected

- Fluid Challenge: 500-1000 mL Over 1 Hour

What is a fluid challenge

How much fluid will be excreted vs how much intake

Nutrition therapy for AKI

- AKI: Causes Increased Rate of Protein Breakdown in Muscles

- Registered Dietician: Calculates Protein & Caloric Needs

- Assess Food Intake q Shift

- Oral Supplements, Enteral or Parenteral Nutrition

- Kidney-Specific Formulations

What diet should someone follow if they have AKI?

Limited sodium, potassium, and phosphorus, and may involve fluid restrictions. Protein and caloric needs will vary.

Stage 1 CKD

Normal Kidney Function

Either Abnormal Urine Findings, Structural Abnormalities, or Genetic Traits r/t Kidney Disease

GFR > 90 mL/min

Manage: HTN, DM, Anatomic or Urinary Tract Abnormalities

Screen for Genetic Kidney Disease

Reduce Exposure to Nephrotoxins

CKD Stage 2

Mild CKD

Slightly Reduced Renal Function

Lab Values Point to Kidney Disease

Albuminuria may be Present (Marker of Kidney Damage)

Increased Dilute UO

Structural Changes Present

GFR 60-89 mL/min

Focus on Reduction of Risk Factors

CKD Stage 3

Moderate CKD

GFR 30-59 mL/min

Albuminuria Present

Implement Strategies to Slow Disease Progression

Restrict Fluids, Proteins, & Electrolytes Like Potassium & Salt

CKD Stage 4

Severe CKD

GFR 15-29 mL/min

Jaundice Around the Eyes May be Present

Manage Complications

Discuss Patient Preferences & Values

Educate About Options

Prepare for Renal Replacement Therapy

CKD Stage 5

End-Stage Kidney Disease (ESKD)

GFR < 15 mL/min

Implement Renal Replacement Therapy or Kidney Transplantation

The lower the GFR the (better or worse) the kideys are

worse

AKI Prevention

Maintenance of fluid volume before and after surgery or diagnostic procedures or when nephrotoxic drugs or contrast agents are used

AKI Education

Low protein/high fluid

malnutrition

Daily weight after voiding

Daily BP

Why is protein rough on the kidneys

Stress on the kidneys; Protein is broken down into amino acids, which the kidneys must filter and remove from the blood. High protein intake increases the workload on the kidneys, as they have to process a larger amount of waste products

Meds for AKI

ACEs and ARBs

Diuretics (e.g., furosemide, hydrochlorothiazide)

Non-steroidal anti-inflammatory drugs (NSAIDs, e.g., ibuprofen, naproxen): Can worsen AKI but may be used cautiously in low doses.

Medications to Remove Toxins:

Dialysis: A procedure that removes waste products and excess fluid from the blood.

Antibiotics: If AKI is caused by an infection, antibiotics may be necessary.

Antidotes: Specific antidotes may be used for certain types of kidney injury, such as lithium or ethylene glycol poisoning.

Medications to Support Vital Functions:

Potassium-binding resins (e.g., sodium polystyrene sulfonate): Help control high potassium levels.

Calcium supplements: May be needed if calcium levels are low.

Vitamin D supplements: Helps maintain healthy calcium levels.

What do the kidneys do?

Excrete water and waste (filter blood and produce urine)

What important hormones do the kidneys excrete?

erythropoietin (stimulates red blood cell production), calcitriol (the active form of vitamin D, important for calcium absorption), and renin

What are important hormones that the kidneys regulate/respond to?

Aldosterone: A hormone from the adrenal gland that signals the kidneys to reabsorb sodium and excrete potassium, helping to regulate blood pressure and fluid balance.

Antidiuretic Hormone (ADH): From the pituitary gland, it regulates water excretion by telling the kidneys to reabsorb more water.

Parathyroid Hormone (PTH): Influences the kidneys to reabsorb calcium and excrete phosphate

What are things that are bad for the kidneys (just in general)

HTN, heart problems, nephrotoxic agents (contrast, NSAIDs, metformin, -mycins), CKD

AKI will have a (fast or slow) onset?

fast

Can you bave an AKI with CKD?

Yeppers

What is CKD

chronic kidney disease; progressive, irreversible loss of kidney function

S/s of CKD

- hyperkalemia

- HTN

- anemia

- calcium and vitamin D deficiency

- oliguria

- azotemia

- decreased GFR

- fluid retention

- uremia

CKD vs AKI

CKD = longstanding disease to the kidneys leading to renal failure

AKI = abrupt decrease in renal function; kidney function can return but not at 100%...can also lead to CKD

CKD management and treatment

Same as AKI but with NO DIURETICS

- Restricted protein, sodium, phos, mag intake

- Increase Calcium!

-

Preventing CKD

Be healthy, no NSAIDS for long periods of time, family history...

Meds for CKD

digoxin, sodium polystyrene, epoetin alfa, ferrous sulfate, calcium carbonate, furosemide or bumetanide

Hemodialysis

A technique in which an artificial kidney machine removes waste products from the blood

Good meds to give before hemodialysis

- Metformin

- Heart meds

- Maybe not BP meds (it'll be washed out and dialysis can make you hypotensive)

What is intermittent hemodialysis

Scheduled 3x a week sessions for 4-5 hrs

Weight/fluid balance important

Quality of life? not ideal, advance directives, EOL care talks...

Typically through an arteriovenous fistula or hemodialysis catheter.

4-5 L of fluid is removed so the patient is going to feel wiped out afterwards

Hemodialysis complications

- Thrombosis of AV Access

- Stenosis of AV Access

- Infection:

o Prepare Skin W/Antibacterial Agent Prior to Access

o Use Agents Approved for the Dialysis Catheter

- Aneurysms: Formed From Repeated Needle Punctures & Pressure Exerted During Dialysis

o Too Large, Surgical Removal & Resection Needed

- Ischemia: Fistula Blocks Blood Flow to Tissues Below Site

o Cold, Numb Fingers

o New Fistula Needed & Old One Deactivated

o Heart Failure

Hemodialysis management

Fistula

- Assess bruit/thrill

- Can get clotted

- If absent = medical emergency

- Patient complaint of numbness/tingling same arm as fistula: Take pulse and call provider

- No BP/IV starts/venipunctures

Medication considerations

Fistula care

No BP, blood draw, IV, injection in extremity

Monitor patency (bruit or thrill)

Note temp. and capillary refill time

Avoid restriction clothing, watches, jewlery

Protect from injury

How soon can a fistula be used once placed?

8 to 12 weeks wait time, so until then, HD is done through a port (HD catheter)

What is CRRT?

Continuous renal replacement therapy which typically done in an ICU setting and is continuous so that the client doesn't have drastic fluid shift. It's never more than 80mL of blood out of the body at 1 time being filtered and therefore does not stress the cardiovascular system as much.

Continuous Renal Replacement Therapy (CRRT)

o Differences from HD and PD.

o ICU floor

o Concept remains the same, we're 'cleaning' the blood.

o Gentler, less instability.

o Indicated for patients who would not be able to hemodynamically tolerate HD.

peritoneal dialysis

dialysis in which the lining of the peritoneal cavity acts as the filter to remove waste from the blood

Can peritoneal dialysis be done at home?

Yeppers

What should the patient have in order to do peritoneal dialysis at home?

o Clean Room

o Space for Dialysis Supplies & Dialysis Machine

o Additional Storage for 6 weeks of Supplies

o Care Partner to Help or be with During Treatments

Access & Preparation Requires Sterile Technique

Complications of peritoneal dialysis

High Risk of Peritonitis (red, pain, puffy at site, cloudy output), HERNIAS, pulmonary issues (plural effusions... so evaluate their ability to breathe...)

Is it normal to experience pain with peritoneal dialysis?

Possily.. Might occur in the first 1-2 Weeks

Warm Dialysate Using Warming Chamber (No Microwave)

Who is at risk for Dialysis Disequilibrium Syndrome?

patients who are skipping dialysis treatments

Dialysis Disequilibrium Syndrome

caused by the rapid removal of urea during hemodialysis; Caused by osmosis - Urea concentration in brain is different than in blood. Takes longer to shift levels than what is done in dialysis.

How to treat Dialysis Disquilibrium Syndome?

Slow it down or stop it altogether

s/s of dialysis disequilibrium syndrome

Headache, nausea, hypotension, restlessness, confusion, blurred vision, seizures DURING dialysis

What would dehyration labs look like

increased serum osmolality, higher levels of blood urea nitrogen (BUN) and creatinine, and concentrated urine.

Blood tests can also show elevated hematocrit and hemoglobin levels due to lower plasma volume, which can temporarily make anemia look worse.

Electrolyte levels like sodium may be higher, although they can sometimes be normal or low

After a kidney transplant, should the patient be peeing a lot?

Yes. We don't want dehydration. We want a happy, perfusing kidney.. and it has a lot to do after a transplant.

Would a patient with a newly transplanted kidney still need dialysis?

Possibly! Depends. The kidney may need extra help adjusting.

Hyper acute rejection

- Onset: Within 48 hrs of Surgery

- Increased Temperature

- Increased BP

- Pain at Transplantation Site (Iliac Fossa)

- Immediate Remove of Transplanted Kidney Required

- Return to Dialysis

Acute rejection

- A Week to Several Weeks after Surgery

- Oliguria or Anuria

- Temperature > 100

- Increased BP

- Enlarged, Tender Kidney

- Lethargy

- Elevated Creatinine, BUN, & Potassium Levels

- Fluid Retention

- Increased Dose of Immunosuppressive Drugs

Chronic rejection

- Occurs Gradually Over Months to Years

- Gradual Increase in BUN & Serum Creatinine

- Fluid Retention

- Electrolyte Imbalance (BUN and Cr will increase

- Fatigue

- Conservation Management Until Dialysis Required

What is the primary cause of kidney transplant failures?

Lack of adherence to immunosuppressive meds

What is MS

Multiple Sclerosis

Multiple sclerosis is characterized by what

Autoimmune stuff- the immune system attacks healthy nerve tissue throughout the entire body.

What disease is characterized by autoimmune problems affecting myelin and nerve fibers? It leads to disability with variable progression and affects more women than men. S/S can include fatigue, headache, numbness and tingling, dizziness, vision problems, and walking problems.

MS

How do you diagnose MS?

Review of s/s

Abnormal CSF (increased myelin and WBC)

MRI shows plaques (2 different areas of white matter demyelination)

LP shows increased lymphocytes

Management of MS

Treatment Strategies: treatment of relapses, symptom management, disease modification, rehabilitation, psychosocial support

Preventing MS

Healthy lifestyle and diet

Risk factors for MS

COLDER CLIMATES

NORTHERN EUROPEAN ANCESTRY

1ST DEGREE RELATIVE

ONSET 20-50 YEARS OLD

Effects women more than men

Education for MS

AVOID OVEREXERTION

AVOID STRESS

AVOID EXTREME TEMPERATURES

AVOID EXTREME HUMIDITY

AVOID PEOPLE WITH INFECTIONS

ALWAYS BALANCE REST WITH ACTIVITY

Medications for MS

-corticosteroids are used to decrease inflammation

-immunomodulators slow progression and reduce number of attacks

-monoclonal antibodies, natalizumab (tysabri, reduces the frequency of attacks with relapsing MS, but is given only by specifically trained MDS)

-antispasmotics such as baclofen (lioresal) can reduce muscle spasm

-CNS stimulants can control fatigue

-antidepressants can assist with depression

-PTs with urinary retention can be treated with bethanechol (ureocholine)

Multiple Sclerosis

A chronic autoimmune disease that affects the central nervous system, leading to the deterioration of the myelin sheath around nerve fibers.

Myelin

A protective sheath that surrounds nerve fibers, facilitating the rapid transmission of electrical signals in the nervous system.

Autoimmune Disorder

A condition in which the immune system mistakenly attacks the body's own tissues, leading to inflammation and damage.

Symptoms of MS

Common manifestations of multiple sclerosis include fatigue, difficulty walking, numbness, vision problems, and cognitive changes.

Relapsing-Remitting MS

The most common form of multiple sclerosis, characterized by episodes of new or increasing neurological symptoms followed by periods of recovery.

Secondary Progressive MS

A stage of multiple sclerosis that follows relapsing-remitting MS, where the disease progressively worsens over time.

Primary Progressive MS

A form of multiple sclerosis characterized by a gradual accumulation of disability from the onset, without distinct relapses.

MRI for MS

A diagnostic imaging technique often used to visualize lesions in the brain and spinal cord associated with multiple sclerosis.

Corticosteroids for MS

Anti-inflammatory medications commonly used to manage acute relapses of multiple sclerosis.

Lifestyle Management of MS

Strategies such as exercise, diet, and stress management that can help improve quality of life for individuals with multiple sclerosis.

Injury to T6 and above poses a risk for these two problems

neurogenic shock and autonomic dysreflexia

What is neurogenic shock

A type of distributive shock caused by loss of sympathetic nervous system tone, leading to vasodilation, hypotension, and bradycardia.

What causes neurogenic shock

Spinal cord injury (typically above T6), spinal anesthesia, or severe head injury that disrupts autonomic pathways.

What happens to blood vessels during neurogenic shock

blood pooling, decreased venous return, and decreased cardiac output.

s/s of neurogenic shock

Hypotension

Bradycardia

Warm, dry skin (due to vasodilation)

Poikilothermia (inability to regulate body temperature)

Neurogenic vs hypovolemic shock

Neurogenic shock presents with bradycardia and warm skin, while hypovolemic shock has tachycardia and cool, clammy skin.

Nursing interventions for neurogenic shock

Maintain airway and oxygenation

Stabilize spinal injury (immobilization)

Administer IV fluids for hypotension

Vasopressors (e.g., norepinephrine) to support BP

Atropine for bradycardia

Monitor temperature and prevent hypothermia

Patient education for neurogenic shock

t's a temporary condition caused by nerve damage

Stabilization and careful positioning are key

Long-term outcomes depend on spinal cord recovery

What is autonomic dysreflexia?

A life-threatening emergency that occurs in patients with spinal cord injury (usually at or above T6), caused by an excessive, uncontrolled sympathetic response to a noxious stimulus below the level of injury.

Triggers fo autonomic dysreflexia

Bladder distention (most common)

Bowel impaction

Tight clothing or devices

Skin irritation or pressure ulcers

Pain or temperature extremes

What happens in the body during autonomic dysreflexxia

Noxious stimuli below the injury trigger massive sympathetic discharge → vasoconstriction below injury → severe hypertension → baroreceptors trigger parasympathetic response above injury → vasodilation and bradycardia.

s/s of autonomic dysreflexia

Severe, pounding headache

Sudden hypertension (systolic ↑ 20-40 mmHg above baseline)

Bradycardia

Flushed skin, sweating above injury

Cool, pale skin below injury

Nasal congestion and blurred vision

Autonomic dysreflexxia nursing interventions

Sit the patient upright to lower BP.

Loosen tight clothing.

Check bladder: empty with catheter if distended.

Check bowel: remove impaction if safe.

Monitor BP every 2-3 min.

Administer antihypertensives (nifedipine, hydralazine) if unresolved.

Identify and remove the cause.

NITRATES

Preventing autonomic dysreflexia

Maintain regular bladder and bowel programs

Ensure catheter patency

Prevent skin irritation or pressure injuries

Educate on avoiding tight clothing

Teach early recognition of symptoms

Patient education on autonomic dysreflexia

Recognize early warning signs (headache, flushing, sweating)

Sit up immediately and call for help

Avoid triggers through bladder, bowel, and skin care routines

Carry emergency treatment instructions or card

Complications of autonomic dysreflexxia

Hypertensive stroke

Seizures

Retinal hemorrhage

Myocardial infarction

How to treat autonomic dysreflexia

treat the cause!

A patient that is LESS SENSITIVE TO TEMPERATURES means.....

higher risk for autonomic dysreflexia

Severe hypertension + headache + flushed/sweaty skin above the injury

Autonomic dysreflexia