NUR 265 Exam 1 (Answered) Complete Solution

NUR 265 Exam 1 (Answered) Complete Solution Acute Kidney Injury ● Risks: REDUCED PERFUSION (reduced blood flow to the kidneys) ○ blood/fluid loss ○ Blood pressure drugs resulting in hypotension ○ Heart attack/heart failure (low ejection fraction and low cardiac output) ○ Infection (sepsis/septic shock) ○ Liver failure ○ Use of aspirin, NSAIDs (advil, motrin, naproxen) ○ Severe allergic reactions (anaphylaxis) ○ Severe burns ○ Severe dehydration ○ Renal artery stenosis ○ bleeding/clotting in the kidney blood vessels (coagulopathy) ○ atherosclerosis/cholesterol deposits (block blood flow to the kidney) ■ Get history ^ (surgery, transfusions, meds), recent contrast dye (damaging to kidneys), coexisting conditions (hypertension, diabetes, pre-existing lower GFR), acute illnesses ● Signs and Symptoms: oliguria, anuria, increased creatinine and BUN, urine concentrated (specific gravity greater than 1.030), azotemia (retention of nitrogenous wastes) ● Diagnostics: ultrasound of kidneys (obstruction of stones, patency of ureters), CT scan WITHOUT contrast, KUB X-ray, nuclear medicine -MAG3 (measures GFR), cystoscopy or retrograde pyelography (obstruction of lower tract), biopsy (prepare patient for hypotension/hypertension) ● Labs: BUN and creatinine (increased), serum electrolytes (especially K+→ ECG=bradycardia, peak T wave, wide QRS, ST elevation), serum osmolarity (low), urine specific gravity (high), GFR (not accurate during acute) ○ IF ONLY BUN ELEVATED=DEHYDRATION →creatinine=#1 lab for kidney function ● Meds: ○ Diuretics- increase UOP, get rid of retained fluid and electrolytes (used in the beginning, does not preserve kidney function or stop AKI) ○ Fluid challenge: 500-1000 mL of N.S. bolus (to see how the kidneys are functioning) MONITOR FOR FLUID OVERLOAD (ESPECIALLY RESPIRATORY DISTRESS) ● Nursing interventions: ○ PRIORITY= PREVENTING AKI (promoting daily hydration) ■ Evaluate fluid status ■ Strict I&O ■ Body weight ■ Characteristics of urine ■ REPORT IF UOP 0.5 mL/kg/hour (especially if persisting over 2 hours) ○ Monitor MAP (maintain 80 mmHG in high-risk or critically ill) ○ Reduce risk factors (nephrotoxic agents, contrast media) ○ Diuretic and fluid challenge, hemodynamic monitoring (if fluid volume overload do not use) ● Diet: catabolism=protein breakdown=breakdown of muscle protein and increased azotemia ○ NO dialysis: 0.6 g/kg of body weight or 40 g/day of protein ○ Dialysis: 1-1.5 g/kg of protein ○ Sodium: 60-90 mEq/kg ○ If high K+: restricted to 60-70 mEq/kg ○ Fluid: urine output + 500 mL Fluid volume overload ○ Crackles ○ Anasarca (swelling all over body) ○ Decreased O2 sat ○ Increased RR ○ LOC changes (confusion) ○ Restlessness (not normal to be restless for no reason) ■ Treated with: diuretics, dialysis, or paracentesis (removal of excess fluids), fluid and sodium restrictions Hypoperfusion/hypoxia →reduced blood volume ○ MAP 65 mmHg ○ Tachycardiac ○ Thready peripheral pulses ○ Decreased cognition ■ Treated with: IV fluids and possible blood transfusion Chronic Kidney Disease ● Risks: diabetes, hypertension, glomerulonephritis, PKD, gout, lupus, lead poisoning, pyelonephritis ● Signs and Symptoms: (CKD affect entire body →TOXINS LEFT IN BLOOD ) ○ Reduced GFR ○ Uremia (azotemia with symptoms)- metallic taste, anorexia, N/V, muscle cramps (hyperkalemia), uremic frost, pruritus, fatigue, hiccups, edema, dyspnea, paresthesia (gabapentin given) →end-stage (stage 4 and 5/maybe severe AKI) ○ Metabolic: buildup of urea and creatinine (expected=increased BUN & creatinine), Na+ issues (hyponatremia=early polyuria, later=hypernatremia & oliguria/anuria), hyperkalemia (always monitored) →metabolic acidosis →pH and HCO3 decrease (WATCH RR- COMPENSATION=KUSSMAUL’S), Ca+/phosphorus/vitamin D concerns (phosphorus increase=Ca+ and vitamin D decrease= osteoporosis (fracture/cramps) →FALL RISK ○ Cardiac changes: hyperlipidemia, hypertension, H.F.(F.V.O.)/S3 (S3=first sign of H.F.), crackles, pulmonary edema (pink frothy sputum=medical emergency), tachypnea, hyperpnea, peripheral edema, JVD, pericarditis, cardiac tamponade BP★ aldosterone= increase Na+ and fluid=increase ○ Hematologic: anemia, low iron & folic acid, decreased immunity (erythropoietin made in the kidneys. EPO=stimulates production of RBC=H&H decreased=anemia) ○ GI: uremic fetor (ammonia smelling bad breath), stomatitis, PUD →uremia symptoms (can cause constipation and diarrhea) ○ Neurological: ataxia, peripheral neuropathy, tremors, seizure, coma ○ Musculoskeletal: bone pain, muscle weakness, pathological fractures (decreased Ca+ and vitamin D) ● Diagnostics: kidney ultrasound or CT without contrast medium (obstruction), kidney EXPECTED to shrink with long-term ESKD (unless polycystic kidney disease) ● Labs: Severe= creatinine and BUN to determine if uremia is present, creatinine increases gradually over time reaching 15-30 mg/dL, BUN directly related to protein intake ● Meds: Antihypertensive (ACEs, calcium channel blockers, thiazides) →diuretics won’t help with ESKD (only if elimination is still present →Loop diuretics), vitamins and minerals (deficient in folic acid, vitamin B/D), Erythropoietin-stimulating agents, parathyroid hormone modulator (Cinacalcet) ● Nursing interventions: manage fluid volume ○ Assesses for FVO Q 4 hours (lungs, heart, O2 sat) ○ Strict I&O and daily weights (stick to routine) ■ 1 kg=1 L of fluid ○ Diuretics →not helpful in ESKD ○ Monitor serum electrolytes (treat high K+ →high potassium EXPECTED, but still need to treat) ○ Treat hypertension →ACEs (-pril), calcium channel blockers (-dipine), thiazides (loop diuretic) ○ Dialysis (hemodialysis or peritoneal dialysis) ● Diet/Teaching: ○ Limited protein intake ○ Potassium and sodium restriction ○ High calorie supplements needed ○ Phosphorus restriction ■ Binders at meals (Calcium Carbonate- taken with meals/snacks and excretes phosphorus through stool) ○ Give calcium and vitamin B & D ○ Avoid antacids contain magnesium (potassium and magnesium act similarly→ if high=less active) Metabolic acidosis →Kussmaul’s breathing (from hyperkalemia) ○ N/V ○ Fast breathing (rapid and shallow= Kussmauls) ○ Lethargy ○ Confusion ■ Treated: IV sodium bicarbonate Hemodialysis complications: thrombosis/stenosis, infection, aneurysm formation, ischemia to distal area ○ Dialysis disequilibrium syndrome= N/V, headache, restlessness, muscle cramps (TAKING TOO MUCH TOO FAST) 1. Stop the hemodialysis 2. Prepare to give anticonvulsants (benzodiazepines) Peritoneal dialysis complications: ○ Peritonitis= increase in temperature, tachycardia, rigid board-like abdomen with cloudy effluent that is foul smelling (drainage) →dialysate drainage should be clear/pale yellow ■ Prevent: masking yourself and patient, sterile gloves to remove dressing, aseptic technique (teach patients how to do this at home) ○ Pain →should not occur after a week or two of PD. (cold dialysate can increase discomfort and should be warmed using heating pad or warming chamber NOT microwave) ○ Exit site/tunnel infection ■ Symptoms: redness, tenderness, and pain ■ Treatment: antimicrobials (deep infections may require removal) ○ Poor dialysate flow →repositioning patient! ○ Dialysate leakage →beginning=bloody/blood tinged. Should become clear and light yellow (observe and document any changes in outflow color) ○ Bleeding at the site →expected when the catheter is first placed ○ Bowel perforation (drainage with be brown in color) →MEDICAL EMERGENCY ○ Warm dialysate decreases BP (vasodilation) →EXPECTED unless severe drop in blood pressure ■ Fluids (100-250 mL N.S. bolus →may need to be given twice) , oxygen, modified trendelenburg, drop temperature