Chapter 68: Care of Patients with Acute Kidney Injury and Chronic

Kidney Disease Outline

1. Kidney Serum Creatinine:

Function Blood Males- 0.6-1.2 mg/dl
Studies: Females- 0.5-1.1 mg/dl

Significance of Abnormal Findings:

- An increased level indicates kidney impairment
- A decreased level may be caused by a decreased muscle mass

Blood Urea Nitrogen (BUN):

10-20 mg/dl

Older Adults:
60-90: 8-23mg/dl
> 90: 10-31 mg/dl

Significance of Abnormal Findings:

- An increased level may indicate liver or kidney disease,
dehydration, or decreased kidney perfusion, a high-pro- tein
diet, stress, steroid use, GI bleeding,or other situa- tions in
which blood is in body tissues
- A decreased level may indicate malnutrition, fluid volume
excess, or severe hepatic damage

BUN/Creatinine Ratio:
6-25 (BUN divided by Creatinine)

Significance of Abnormal Findings:

- An increased ratio may indicate fluid volume deficit,
obstructive uropathy, catabolic state, or a high-protein diet
- A decreased ratio may indicate fluid volume excess

Specific Gravity: 1.005 - 1.030

pH: Average: 6; POssible range: 4.6-8

Protein: 0-0.8 mg/dl

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Glucose: Negative from fresh specimen

Ketones: None
Billirubin: None
Parasites: None
Bacteria: <1000 colonies/mL
Leukoesterase: None Nitrites:
None

2. Kidney Disease Serum Creatinine:

Laboratory Male: 0.6-1.2 mg/dl
Pro- file: P. Female: 0.5-1.1 mg/dl
1415 Older Adults: Decreased

Values in Kidney Disease:

In CKD:
- May increase o.5-1.0 mg/dl every 1-2 years
- May be as high as 15-30 mg/dl before manifestations of
severe ckd are present

Values in Acute Kidney Injury:

- Increase of 1-2mg/dl every 24-48 hr
- Increase in 1-6mg/dl in 1 week or less

Blood Urea Nitrogen:

10-21 mg/dl
Older Adults: Slightly increased

In CKD:
May reach 180-200 mg/dl before manifestations develop

In AKI:
Often increases by 10-20 mg/dl at same pace as serum
creatinine
May reach 80-100mg/dl within 1 week

Serum Sodium: 136-145 mEq/L

Normal, increased; or decreased

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Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Serum Potassium: 3.5-5.0 mEq/L
Increased

Serum Phosphorous (Phosphate): 3.0-4.5 mg/dl Increased

Serum Calcium:
Total Calcium: 9.0-10.5mg/dl
Ionized Calcium: 4.5-5.6 mg/dl
Older Adults: Slightly Decreased
Decreased

Serum Magnesium: 1.3-2.1 mEq/L

Increased

Serum Carbon Dioxide Combining Power (Bicarbonate): 23-

30 mEq/L
Decreased

Arterial Blood pH: 7.35-7.45

Decreased (Metabolic Acidosis) or Normal

Arterial Blood Bicarbonate:

21-28 mEq/L
Decreased

Arterial Blood PACO2:

35-45 mm Hg

Hemoglobin:
Female: 12-16 g/dl
Male: 14-8 g/dl
Older Adults: Slightly Decreased
Value: Decreased

Hematocrit:
Female: 37-47%
Male: 42-52%
Older Adults: Slightly decreased

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Value: Decreased

Blood Osmolarity: 285-295 mOsm/kg

Elevated in volume-depleted state, increasing the risk for
acute kidney injury

3. Acute Kidney Pathophysiology:

In- jury (AKI): - AKI is a rapid reduction in kidney function resulting in a
failure to maintain fluid and electrolyte balance and acid-
base balance

- Severity is based on increases in serum creatinine and

decreased urine output

- Occurs most often in hospitalized adults who are older or

how have pre-existing hypertension, diabetes, peripheral
vascular disease, liver disease, or chronic kidney disease

Types:
- Prerenal-Reduced perfusion
- Intrarenal-Damaged kidney tissue
- Postrenal- Obstruction of urine flow
- Prerenal azotemia

Causes:
- Hypovolemic shock
- Heart failure

Health Promotion:
- Accurately measure intake and output and cjeck body
weight to identify change sin fluid balance
- Report to HCP a urine output of less than 0.5mL/kg/hr
- SIgnificant increase in creatinine, especially hen the
increase occurs over hours or a few days, is a concern and
should be reported urgently to HCP
- If a patient is to receive a known nephrotoxic drug, closely
monitor lab values, including BUN, creatinine, and drug peak
and trough levels for indications of kidney function

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Objective and Subjective Data:
- Increased Creatinine, BUN, Nephrotoxic substances,
oliguria

- Pain in the flank area

- History of cancer- Urinary obstruction

4. Phases of Acute - Rapid decrease in kidney function leads to collection of

Kidney Injury: metabolic wastes in the body

Phases:
- Onset
- Oliguric
- Diuretic
- Recovery

- Acute syndrome may be reversible with prompt interven-

tion

5. Patient Care Assessment:

for AKI: - Ask about recent surgery or trauma, transfusions, or other
factors about recent surgery or trauma that might lead to
reduced kidney blood flow
- Obtain drug history, especially antibiotcs and NSAIDs
- Coexisting conditions: advanced age, diabetes mellitus, long-
term hypertension, systemic lupus, major or systemic infection
(sepsis), systemic inflammation
- Anticipate AKI following hypotension, shock, burns, or
heart failure exacerbation
- Hx of urinary obstructive problems
- Cancer history that may cause urinary obstruction

Physical Assessments:
- AKI progresses that patient may: Develop fluid overload,
including pulmonary crackles, dependent and general- ized
edema, decreased oxygenation, increased respirato- ry rate and
dsypnea.

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Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Lab Assessment:
- Rising creatinine
- Rising BUN and abnormal electrolyte values
- Urine may be dilute with a specific gravity near 1.000 or
concentrated with a gravity greater than 1.030

Imaging Assessment:
- Ultrasonography diagnoses kidney and urinary tract ob-
struction

- CT scans with dye can determine adequacy of kidney

blood flow and identify obstruction or tumors

- X-Rays of the (KUB) may b used to provide initial screen-

ing

Other Diagnostic Assessment:

- Kidney biopsy is performed if the cause of AKI is uncer- tain
and manifestations persist or an immunologic disease is
suspected

Interventions:
- Current guidelines suggest that a mean arterial pressure
(MAP) of 65 mm Hg be maintained to promote kidney
perfusion
- Not all patients have oliguria
- During AKI, with high-volume urine output, hypovolemia
and electrolyte loss are the main problems

Drug Therapy:
- In patients with fluid overload, 500 - 1000mL of nss may be
infused over 1 hour

Nutrition:
- Have a high catabolism of protein breakdown
- Catabolism causes the breakdown of muscle for protein and
increases azotemia
- For the patient who does not require dialysis, 0.6g/kg of
body weight or 40g/day of protein

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
- For patients who require dialysis, protein level needed with
range from 1-15g/kg
- As a rule, special tube feedings or kidney patients are lower
in NA, K, Phosphorous, and higher in calories than standard
feedings

6. Chronic - Slow, progressive, irreversible kidney injury; kidney func-

Kidney tion does not recover
Disease (CKD):
- End-stage kidney disease (ESKD)
- Azotemia: Buildup of nitrogen-based wastes in blood

- Uremia: a raised level in the blood of urea and other ni-

trogenous waste compounds that are normally eliminated by
the kidneys.
Key Features:
- Metallic taste in mouth
- Anorexia
- N&V
- Muscle Cramps
- Uremic "Frost" on Skin
- Itching
- Fatigue and Lethargy
- Hiccups
- Edema
- Dyspnea
- Paresthesias

- Uremic syndrome: a serious complication of chronic kidney

disease and acute kidney injury (which used to be known as
acute renal failure)

7. Uremic Frost Urea crystals and salt

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline

8. Stages of CKD: - Reduced renal reserve

- Reduced glomerular filtration rate (GFR)

- ESKD-End stage kidney disease

- Severe impairment of fluid and electrolyte balance and

acid-base balance

- Without replacement and therapy death can occur

Kidney changes:

Metabolic changes:
- Urea and creatinine

Electrolyte changes:
- Sodium
- Potassium
- Acid-base imbalance
- Calcium and phosphorus

Cardiac changes:
- Hypertension
- Hyperlipidemia
- Heart failure
- Pericarditis
- Hematologic changes
- GI changes

9. Clinical Manifes- Neurologic- Lethargy, Depression

tations for CKD:

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
In-

10. Assessments
for CKD:

11. Priority
Nursing Care:

12. Table 68-1 Char-

acteristics of
Acute Kidney

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
C rtension Respiratory- Dyspnea

a Hematologic- Anemia: decreased erythropoetin GI-

r Nausea and vomiting

d Skeletal- Bone disease from hypocalcemia

i Urinary- Progression from polyuria, to oliguria to anuria

o Skin- Darkening or yellowing of skin tone Psychosocial:

v Depression

a Laboratory:

s Imaging:

c Dietary restrictions:

u Uremic frost:

l Muscle strength, energy:

a Family members:

r Excess fluid volume:

- Decreased cardiac output:

Recombinant human erythropoietin:

H Interdisciplinary team:

y Acute Kidney Injury:

Onset: Sudden (Hours-Days)
p

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
jury and Chronic % of Nephron Involvement: 50-95%
Kidney Disease:
Duration: May not progress; full recovery (return to base-
line) possible
ESKD occurs in 10-20% with lifetime reliance on dialysis or
kidney transplant

Prognosis: Good when kidney function is maintained or

returns; High mortality associated with renal replacement
therapy requirements of prolonged illness

Chronic Kidney Disease:

Onset: Gradual (Months-Years)

% of Nephron Involvement:
- Varies by stage; generally symptomatic with 75% loss and
dialysis ith 90-95% loss

Duration: Progressive and permanent; Treatment and

lifestyle can slow progression and delay onset of ESKD

Prognosis: Fatal without a renal replacement therapy (dial- ysis

or transplantation); Reduced life span and potential for
complex medical regimen even with optimal

13. 5 D's of Manag- 1. Diet

ing Renal 2. Drugs
Failure: 3. Dialysis or Donated Kidney
4. Discipline
5. Dying with Dignity

14. Hemodialysis: Patient selection-Depend on the manifestation and

glomerular filtration rate

Dialysis settings-Depending on the pt's needs

Procedure- technique in which substances move from the

blood across a semipermeable membrane into a dialysis
solution
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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline

Anticoagulation- Clotting can occur during dialysis

15. Subclavian These catheters are radiopaque tubes that can be used for
Dialy- sis hemodialysis access.
Catheters:
The Y-shaped tubing allows arterial outflow and venous
return through a single catheter.

A. Mahurkar catheter, made of polyurethane and used for short

term access.

B. A PermCath catheter, made of silicone and used for long

term access.

16. Hemodialysis
Circuit:

17. Vascular Access: Arteriovenous (AV) fistula or graft for long-term permanent
access

Hemodialysis catheter, dual or triple lumen, or AV shunt for

temporary access

Precautions- Assess for adequate circulation of the fistula or

graft. Auscultate or palpate over site for bruit or a thrill.

Complications-Thrombosis, infections, stenosis

Vascular Access Complications:

- Thrombosis or stenosis
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Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
- Infection

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
- Aneurysm formation
- Ischemia
- Heart failure

18. Hemodialysis Drugs

Nursing
Care: Postdialysis assessment:
- Hypotension
- Headache
- Nausea, vomiting
- Malaise, dizziness
- Muscle cramps or bleeding

- Dialysis disequilibrium syndrome

19. Complications
of Hemodialysis: - Infectious disease

- Hepatitis B and C

- Human immunodeficiency virus (HIV)

- Involves siliconized rubber catheter placed into abdomi- nal

20. Peritoneal cavity for infusion of dialysate
Dialy- sis:
Types:
Continuous ambulatory (CAPD)- no machine is neces-
sary.

Automated-Used in acute care and ambulatory settings.

Intermittent-Combines osmotic pressure gradients with true

dialysis

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Trans- plantation :

21. Continuous
Am- bulatory
Peri- toneal
Dialysis
(CAPD):

22. Automated
Peri- toneal
Dialysis:

23. Complications
of Peritoneal
Dialy- sis:

24. Nursing Care

for Peritoneal
Dialy- sis:

25. Kidney
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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Continuous-cycle- time, initiate outflow Observe outflow amount
Uses an automated
cycling machine. and pattern of fluid Candidate selection criteria
Exchanges occur at
night when the pt is
sleeping.

- Peritonitis
- Pain
- Exit site/tunnel
infections
- Poor dialysate flow
- Dialysate leakage
- Other complications

Before treatment:
Evaluate baseline
vital signs, weight,
laboratory tests

Continually monitor
patient for respiratory
distress, pain,
discomfort

Monitor

prescribed

dwell

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Donors- living, non-heart beating, and cadaveric donors

Preoperative care- Pre-op exam, NPO, lab eg immunolog- ic

studies.
Immunologic studies

Surgical team-Surgeons, anesthesiologist, nurses

Operative procedure- Organ harvested, kidneys are re-

moved and preserved until implantation

26. Postoperative infarction

Care for Kidney
Transplantation:

27. Patient
diag- nosed
with
pre-renal kidney
injury in most
cases have a
his- tory of
myocar- dial
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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Urologic management:

Assess

ment of

hourly

urine

output

× 48 hr:

Compli

cations:
Rejection-
Immunosuppressive
Drug Therapy

- Acute tubular necrosis

- Thrombosis
- Renal artery stenosis
- Other complications
- Immunosuppressive
drug therapy-Neoral
(cyclosporine)
- Psychosocial
preparation--
Educate patient and
family members on
treatment regi- mens.

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
28. A marathon run-
ner hasn't urinat-
ed much in a few
days and they
have increased
HR and Low BP-
Give fluids/ bot-
tle of water im-
mediately

29. Aspirin, Ibupro-

fen, Naporoxen
can affect
serum
creatinine and
BUN

30. A patient with

AKD and urine
output of
2000ml/day the
main concern
should have re-
garding this
pa- tient is
elec- trolyte
and fluid
imbalance

31. A patient is re-

ceiving 1000ml
of nss; patent
de- velops SOB
so the priority
here is to slow
down the
infusion be-
cause it could be
fluid overload

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
32. If a patient
has increased K,

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 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Creatinine, and
Urine Output of
350ml/day with
that the nurse
must place the
patient on a car-
diac monitor be-
cause the K
level affects the
heart

33. Patient with

a central line
catheter or he-
modialysis the
nurse must
place a heparin
and with or
without saline
after to flush the
line

34. A patient on con-

tinuous venal-ve-
nous hemofilra-
tion a BP of
76/58 is cause
for im- mediate
action

35. Continuum of
care is imper-
ative to posi-
tive patient out-
comes-
Continu- ity of
care is im-
portant to assess
subtle differ-
ences in clients.
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Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
Therefore, the
registered nurse
(RN) who was

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Chapter 68: Care of Patients with Acute Kidney Injury and Chronic
Kidney Disease Outline
assigned to this
client previous-
ly should again
give care to this
client.

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