4800 week 7 renal student
DESCRIPTION
lTRANSCRIPT
Acute Kidney Injury Acute Kidney Injury and Chronic Kidney and Chronic Kidney
DiseaseDisease
2
Challenge Question
• A patient is concerned about her steadily worsening chronic kidney disease and asks you at what point she will require dialysis. Which of the following should you mention?
3
Challenge Question
• A patient is concerned about her steadily worsening chronic kidney disease and asks you at what point she will require dialysis. Which of the following should you mention?
• A. when urine albumin to Cr ratio is great than 25• B when your urine output is less than 0.5 ml/kg/h x 6 hours• C. when your GRF falls below 15mL/min/1.73m2• D. When your urine osmolality is greater than 500
4
Challenge Question
• A patient with chronic kidney disease is receiving an ACE inhibitor. The nurse understands that this medication helps slow the progression of this disease through what process?
5
Challenge Question
• A patient with chronic kidney disease is receiving an ACE inhibitor. The nurse understands that this medication helps slow the progression of this disease through what process?
• A. It lowers the level of the blood glucose• B. It prevents nerphon hyperfiltration• C. It increases the urine output• D. It filters waste from the blood.
6
Challenge Question
• A patient with chronic kidney disease has a serum K of 5 and no changes on the ECG. What is the proper nursing intervention?
7
Challenge Question
• A patient with chronic kidney disease has a serum K of 5 and no changes on the ECG. What is the proper nursing intervention?
• A. Administer sodium polystyrene as an enema• B. Administer IV calcium gluconate• C. Administer IV insulin and dextrose• D. Being dialysis
8
Challenge Question
• A patient with a history of diabetes mellitus has had a procedure using radiocontrast dye. The patient's laboratory results include high urine sodium, urine with muddy-brown granular casts and tubular epithelial cells, and increased blood urea nitrogen (BUN) and serum creatinine. Renal ultrasonography is normal. Urine volume is normal. Which treatment does the nurse anticipate?
9
Challenge Question
• A patient with a history of diabetes mellitus has had a procedure using radiocontrast dye. The patient's laboratory results include high urine sodium, urine with muddy-brown granular casts and tubular epithelial cells, and increased blood urea nitrogen (BUN) and serum creatinine. Renal ultrasonography is normal. Urine volume is normal. Which treatment does the nurse anticipate?
• A. increased fluids• B. renal stent placement• C. irrigation of Foley catheter• D. Diuretics
10
Challenge Question
• A patient has just been diagnosed with type 2 diabetes mellitus. During teaching, what strategy should the nurse emphasize as protective of kidney cells?
11
Challenge Question
• A patient has just been diagnosed with type 2 diabetes mellitus. During teaching, what strategy should the nurse emphasize as protective of kidney cells?
• A. Monitoring glycosylated hemoglobin every 3 months• B. Strict adherence to prescribed weight-loss diet• C. Restriction of sodium-containing beverages and food• D. Strict control of serum glucose levels with diet and medication
12
Challenge Question
• A patient with chronic renal disease is involved in a motor vehicle crash and experiences severe hypovolemia. In caring for this patient in the CCU, which of the following is the most important for the nurse to monitor?
13
Challenge Question
• A patient with chronic renal disease is involved in a motor vehicle crash and experiences severe hypovolemia. In caring for this patient in the CCU, which of the following is the most important for the nurse to monitor?
• A. Blood pressure• B. Fluid volume recovery• C. Urine output• D. Cardiac dysrhythmias
14
Challenge Question
• A patient with chronic renal failure also has chronic anemia, arteriosclerotic disease, and diabetes mellitus. The patient asks the nurse why the anemia is persisting. In answering the patient's question, what should the nurse most consider?
15
Challenge Question
• A patient with chronic renal failure also has chronic anemia, arteriosclerotic disease, and diabetes mellitus. The patient asks the nurse why the anemia is persisting. In answering the patient's question, what should the nurse most consider?
• A. The patient most likely has preexisting chronic anemia• B. Erythropoietin is primarily produced in the kidney.• C. The patient is receiving low-dose aspirin therapy.• D. Chronic renal failure results in persistent uremia.
16
Challenge Question
• Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the
17
Challenge Question
• Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the
• A. BUN and Cr• B. blood glucose• C. bowel sounds• D. level of consciousness LOC
18
28. The nurse assesses the progress of a client diagnosed with acute glomerulonephritis. The nurse is MOST concerned by which finding?
19
28. The nurse assesses the progress of a client diagnosed with acute glomerulonephritis. The nurse is MOST concerned by which finding?
1. Hematuria. 2. Proteinuria.3. Fixed urine specific gravity.4. Urine excretion of 1,500 mL in 24 hours.
20
21
Acute Kidney InjuryAcute Kidney Injury
• Etiology and PathophysiologyEtiology and Pathophysiology• PrerenalPrerenal• IntrarenalIntrarenal• PostrenalPostrenal
22
1. The nurse determines that a patient with oliguria has oliguria of intrarenal acute kidney injury when
23
1. The nurse determines that a patient with oliguria has oliguria of intrarenal acute kidney injury when
1. the serum creatinine level is normal.2. urine testing reveals a specific gravity of 1.010.3. urine testing reveals a low concentration of sodium.4. reversal of the oliguria occurs with fluid replacement.
24
25
RIFLE Classification
• Risk• Injury• Failure• Loss• End-stage kidney disease
26
AKI Clinical Manifestations
• Oliguric phase• Urinary changes• Fluid volume • Metabolic acidosis• Sodium balance
27
AKI Clinical Manifestations
• Oliguric phase• Potassium excess: ECG changes: next slide• Hematologic disorders• Waste product accumulation• Neurologic disorders
28
ECG Changes in Hyperkalemia
29
AKI Clinical Manifestations
• Diuretic Phase• 5 L/day• Hypovolemia• Hypotension• Hyponatremia• Hypokalemia• Dehydration
30
AKI Clinical Manifestations
• Recovery Phase• GFR increases• BUN , Cr: plateau, decrease
31
Acute Kidney Injury: Acute Kidney Injury: Diagnostic Diagnostic StudiesStudies
• HistoryHistory• Urine outputUrine output• Serum CrSerum Cr• UAUA• UltrasoundUltrasound• CTCT• MRIMRI• MRAMRA
32
Acute Kidney Injury: Acute Kidney Injury: CollaborativeCollaborative
• Volume status Volume status • Fluid restriction (600 + previous 24 hours)Fluid restriction (600 + previous 24 hours)• Diuretic therapyDiuretic therapy• I & OI & O• HyperkalemiaHyperkalemia
33
Acute Kidney Injury: Acute Kidney Injury: HyperkalemiaHyperkalemia
• Regular Insulin IVRegular Insulin IV• Sodium BicarbonateSodium Bicarbonate• Calcium Gluconate IVCalcium Gluconate IV• HemodialysisHemodialysis• Sodium polystyrene sulfonateSodium polystyrene sulfonate• Dietary restrictionDietary restriction
34
Acute Kidney Injury: Acute Kidney Injury: RRT RRT indicationsindications
• Volume overloadVolume overload• Elevated KElevated K• Met Acid: HCO3 < 15Met Acid: HCO3 < 15• BUN > 120BUN > 120• Mental status changesMental status changes• Pericarditis, pericardial effusion, cardiac tamponadePericarditis, pericardial effusion, cardiac tamponade
35
Acute Kidney Injury: Acute Kidney Injury: Nutritional Nutritional therapytherapy
• Adequate protein : 0.6 – 2g/kg/dayAdequate protein : 0.6 – 2g/kg/day• Calories: 30 – 35kcal/kgCalories: 30 – 35kcal/kg• Protein 0.8 – 1.0 g/kgProtein 0.8 – 1.0 g/kg
• Potassium restrictionPotassium restriction• Sodium restrictionSodium restriction• Phosphate restrictionPhosphate restriction
36
Nursing Management:Nursing Management:Acute Kidney Injury Acute Kidney Injury
• Nursing Assessment Nursing Assessment • Nursing DiagnosesNursing Diagnoses• PlanningPlanning• Nursing ImplementationNursing Implementation
• Health promotionHealth promotion• Acute interventionAcute intervention• Ambulatory and home careAmbulatory and home care
• EvaluationEvaluation
37
Gerontologic Considerations: Gerontologic Considerations: Acute Renal Failure Acute Renal Failure
-Dehydration-Hypotension- Diuretic therapy-Aminoglycoside therapy-Prostatic hyperplasia-Surgery-Infection-Contrast agents
38
Chronic Kidney DiseaseChronic Kidney Disease
39
43. An elderly client says to the nurse, “I have no energy and it has gotten worse in the last several weeks.” The client has a history of glomerulonephritis and has been taking antacids frequently for the past 2 months. What is the most appropriate FIRST action by the nurse?
40
43. An elderly client says to the nurse, “I have no energy and it has gotten worse in the last several weeks.” The client has a history of glomerulonephritis and has been taking antacids frequently for the past 2 months. What is the most appropriate FIRST action by the nurse?
1. Assess bilateral deep tendon reflexes.
2. Assess for the presence of Trousseau and Chvostek signs.
3. Listen to bowel sounds in all 4 quadrants for 2 to 3 minutes.
4. Ask the client if urine output has decreased during the last week.
41
23. An elderly client is brought by the spouse to the clinic. The nurse notes the client has a 10-year history of chronic renal failure and has been taking over the counter cimetidine (Tagamet) for 2 weeks. It is MOST important for the nurse to investigate which statement made by the client’s spouse?
42
23. An elderly client is brought by the spouse to the clinic. The nurse notes the client has a 10-year history of chronic renal failure and has been taking over the counter cimetidine (Tagamet) for 2 weeks. It is MOST important for the nurse to investigate which statement made by the client’s spouse?
1. “My spouse seems to have diarrhea more often since starting this medication.”
2. “My spouse takes Maalox and Tagamet together.”
3. “My spouse seems to be having more trouble remembering things lately.”
4. “My spouse reports a headache after reading the newspaper.”
43
Chronic Kidney Disease : CausesChronic Kidney Disease : Causes
• Diabetes 50%Diabetes 50%• Hypertension 25%Hypertension 25%• GlomerulonephritisGlomerulonephritis• Cystic diseases Cystic diseases • Urological diseasesUrological diseases
44
45
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• Urinary SystemUrinary System
46
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• MetabolicMetabolic
47
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• Electrolyte & Acid-base ImbalancesElectrolyte & Acid-base Imbalances
48
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• HematologicalHematological
• AnemiaAnemia• Bleeding tendenciesBleeding tendencies• InfectionInfection
49
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• CardiovascularCardiovascular
50
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• RespiratoryRespiratory
• GIGI
51
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• NeurologicalNeurological
52
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• MusculoskeletalMusculoskeletal
53
54
Chronic Kidney Disease: Chronic Kidney Disease: Clinical ManifestationsClinical Manifestations
• IntegumentaryIntegumentary
• ReproductiveReproductive
• PsychologicalPsychological
55
Chronic Kidney Disease: Chronic Kidney Disease: Diagnostic StudiesDiagnostic Studies
• UA: dipstick: UA: dipstick: • ProteinProtein
• Microanalysis: microalbuminuriaMicroanalysis: microalbuminuria
• RBC, WBC, castsRBC, WBC, casts• BUNBUN• CrCr• GFRGFR
56
57
Chronic Kidney Disease: Chronic Kidney Disease: Collaborative Care
• Drug therapy • Hyperkalemia• Hypertension• CKD—mineral and bone disease• Anemia• Dyslipidemia• Complications of drug therapy
58
Chronic Kidney Disease: Chronic Kidney Disease: Collaborative Care
• Nutritional therapy • Protein restriction• Water restriction• Sodium and potassium restriction
59
Nutritional Therapy
• Phosphate restriction• 1000 mg/day• Foods high in phosphate
• Dairy products • Most foods high in phosphate are also high in
protein.
60
When teaching a patient with chronic kidney disease about prevention of complications, the nurse instructs the patient to:
Challenge Question
60
61
When teaching a patient with chronic kidney disease about prevention of complications, the nurse instructs the patient to:
1. Monitor for proteinuria daily with a urine dipstick.2. Weigh daily and report a gain of greater than 4 pounds.3. Take calcium-based phosphate binders on an empty stomach.4. Perform self-catheterization every 4 hours to accurately measure I & O.
Challenge Question
61
62
Nursing Management:Nursing Management:Chronic Kidney DiseaseChronic Kidney Disease
• Nursing AssessmentNursing Assessment• Nursing Diagnoses Nursing Diagnoses
63
64
DialysisDialysis
• Hemodialysis HDHemodialysis HD• Peritoneal dialysis PDPeritoneal dialysis PD
65
Peritoneal Dialysis Peritoneal Dialysis
• https://www.youtube.com/watch?v=CDBNmgkIqMs
66
29. The nurse cares for a client receiving hourly peritoneal dialysis exchanges. During a 1-hour exchange, the nurse infuses 2000 mL of dialysate, and 1900 mL of outflow is returned. During the exchange, the client drinks 8 oz of apple juice and 2 cups of water and voids 150mL of urine. Calculate and record the client’s intake in milliliters.
67
When implementing care for the patient on peritoneal dialysis, the nurse recognizes that dietary needs include an increased amount of
68
When implementing care for the patient on peritoneal dialysis, the nurse recognizes that dietary needs include an increased amount of
1. fat2. protein3. calories4. carbohydrates
69
Peritoneal DialysisPeritoneal Dialysis
• Automated peritoneal dialysis APDAutomated peritoneal dialysis APD
• Continuous ambulatory peritoneal dialysis CAPDContinuous ambulatory peritoneal dialysis CAPD
70
71
Peritoneal Dialysis Peritoneal Dialysis
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 47-6. Peritoneal catheter exit site.
72
Peritoneal Dialysis Peritoneal Dialysis
• Dialysis Solutions and Cycles: 4 per day• Exchange
• Inflow• Dwell• Drain
73
Peritoneal Dialysis Peritoneal Dialysis
• Complications
• Infection: catheter exit site• Peritonitis• Pain
• Hernias• Lower back pain• Protein loss
74
75
Peritoneal Dialysis Peritoneal Dialysis
• Continuous ambulatory peritoneal dialysis
76
32. The nurse counsels a client undergoing continuous ambulatory peritoneal dialysis (CAPD). The nurse determines that further teaching is necessary if the client makes which statement?
77
32. The nurse counsels a client undergoing continuous ambulatory peritoneal dialysis (CAPD). The nurse determines that further teaching is necessary if the client makes which statement?
1. “I need to restrict driving and other outdoor activities when the fluid is in my abdomen.”
2. “I can continue my normal activities immediately after the fluid has drained from my abdomen.”
3. “I will need to follow a low-protein diet while receiving this treatment.”
4. “I might have to buy larger size clothing.”
78
Hemodialysis Hemodialysis
• Vascular Access Sites• Arteriovenous fistulas AVF• Arteriovenous grafts AVG
79
80
81
Hemodialysis Hemodialysis
82
83
84
Hemodialysis Hemodialysis
• 3 days per week: 3 – 4 hours
• Assessment• Weight• BP• Peripheral edema• Lung sounds• Heart sounds• Vascular access• Temp• Skin
85
86
Hemodialysis Hemodialysis
• Complications:
• Hypotension• Muscle cramps• Blood loss• Hepatitis
87
Continuous Renal Replacement Continuous Renal Replacement Therapy Therapy
88
Kidney Transplantation Kidney Transplantation
• Survival rates
• Contraindications• Disseminated malignancies• Refractory or untreated cardiac disease• Chronic respiratory failure• Extensive vascular disease• Chronic infection• Unresolved psych disorders
89
Kidney Transplantation Kidney Transplantation
• Recipient Selection• Compatible blood type deceased• Blood relatives• Emotionally related living donors• Altruistic living donors
• Histocompatibility Studies
90
91
Six days following a deceased donor kidney transplant, the patient develops a temperature of 101.2° F (38.5° C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate
92
Six days following a deceased donor kidney transplant, the patient develops a temperature of 101.2° F (38.5° C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate
1. acute rejection, which is not uncommon and is usually reversible.
2. hyperacute rejection, which will necessitate removal of the transplanted kidney.
3. an infection of the kidney, which can be treated with intravenous antibiotics.
4. the onset of chronic rejection of the kidney with eventual failure of the kidney.
93
Nursing Management: Nursing Management: Kidney Transplant Recipient Kidney Transplant Recipient
• Preoperative CarePreoperative Care• Postoperative Care Postoperative Care
• Fluid and electrolyte balanceFluid and electrolyte balance• InfectionInfection• SurgerySurgery
• Immunosuppressive TherapyImmunosuppressive Therapy
94
Nursing Management: Nursing Management: Kidney Transplant Recipient Kidney Transplant Recipient
• Complications of Transplantation • Rejection • Infection• Cardiovascular disease• Malignancies: 100% greater than general population: immunosuppression• Recurrence of original renal disease• Corticosteroid-related complications