Transcript Acute Kidney Injury

Nursing Care of Individual Experiencing a
Kidney Disorder:
Vascular Disorders
Kidney Trauma
Acute Kidney Injury
modified by Kelle Howard RN, MSN, CNE
revised Fall 2012
Kidney A & P -excellent site for kidney pathophysiology
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I. A&P of the Kidney- (locate structures)
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Fibrous capsule
Renal cortex
Renal medulla
Pyramids
Papillae
Minor calyx
Major calyx
Renal pelvis
Ureter
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II. Functions of the Kidneys
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Regulates ______ & _________ of extracellular fluid
Regulates fluid & electrolyte balance thru
processes of: glomerular__________, tubular
_________, and tubular _____________.
Name some of the F & Es regulated by kidneys
__________________
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Functions of the Kidneys (cont)
• Regulates acid-base balance through _________
• *Hormonal functions: (BP control), multisytem effect.
– Renin Release
RAAS=
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How the RAAS Pathway Works
Valerie Kolmer
2006
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Quick Quiz
Pick the correct pathway of the RAAS
1. Renin – Angiotensin II – ACE – ADH – Aldosterone
2. Renin – Angiotensin I – Aldosterone – ADH –ACE
3. Renin-Angiotensin I-ACE-Angiotensin II-Aldosterone
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Functions of the Kidneys
(cont)
• Erythropoietin Release
– If a patient has acute kidney injury, what
condition will occur?
– WHY???
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Functions of the Kidneys
(cont)
• Activated Vitamin D
– Necessary to absorb Calcium in the GI
tract.
If a patient has acute kidney injury, what will
happen to the patient’s serum calcium level?
__________________
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Review: Functions of the Kidneys
• Regulate
– 1.___________
– 2.___________
– 3.___________
– 4.___________
• Release of ________________
• Activation of _______________
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Nephron- functional unit of the Kidney!
• How the Nephron Works! Click-watch YouTube video!
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Identify the Nephron’s Parts
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Glomerulus
Bowman’s capsule
Proximal tubule
Loop of Henle
Distal tubule
Collecting duct
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Kidney Trauma
 Etiology:
 Blunt force from falls, MVA, sports injuries,
knife/gunshot wounds, impalement, rib fractures
 Common Manifestations:
 Microscopic to gross hematuria
 Flank or abdominal pain
 Oliguria or anuria
 Localized swelling, tenderness, ecchymosis over the
flank area - aka: ____________
 Signs/Symptoms depend upon severity injury
 *Severe blood loss/signs shock
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Kidney Trauma
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Kidney Trauma
• What are common
diagnostic tests used in
kidney trauma?
CT-determine if peritoneal violation
and predict need for laparotomyhere initially see extravasation and
fluid in paracolic gutters (peritoneal
violation) and also a hematoma in
perirenal space
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Kidney Trauma:
Interventions
• Minor Trauma
– Conservative
– Bedrest and close observation
– Monitor for S & S of what?
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Kidney Trauma:
Interventions
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Moderate to Major Trauma
Surgical
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Surgical repair, maybe nephrectomy
Percutaneous arterial embolization during
angiography
Nursing management
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Accurate assessment
Monitor H & H levels
Bedrest, close observation,
evaluate S & S of ____________
Fluid mgt
Prevent complications/monitor I & O
Manage drainage tubes
Daily weights****
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Kidney Surgery:
Nephrectomy
• Indications for Nephrectomy:
– kidney tumor
– massive trauma
– polycystic kidney disease
– donating a healthy kidney
– What are the different types and approaches?
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Kidney Surgery:
Nephrectomy
• Post Op Nursing Management
– Strict I & O
• Urine output should be at least _____.
• What should the UO be if patient had bilateral
nephrectomy? ______.
– Observe urine
– Daily weights
– TCDB & IS
• Incision in flank area
– Medicate for pain as ordered
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Vascular Disorders of the Kidney:
Patho of HTN-Nephrosclerosis
• Development of arterio sclerotic lesions in the
arterioles and glomerular capillaries
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Decreased blood flow which leads to ischemia and
patchy necrosis
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Destruction of glomeruli
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Decrease in _____
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Vascular Disorders of the Kidney:
Renal Artery Stenosis
Definition:
narrowing of one or both renal arteries
due to atherosclerosis or structural
abnormalities.
Common Manifestation:
uncontrollable HTN
medications do not work
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Vascular Disorders of the Kidney:
Renal Artery Stenosis
• Treatment/Collaborative Care
– Diagnostic Tests
• Renal arteriogram-most definitive
– Management
• Conservative-antihypertensive meds
• Percutaneous Transluminal Angioplasty
• Surgical re-vacularization (Graft)
• Nephrectomy
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Vascular Disorders of the Kidney:
Renal Artery Stenosis
– Treatment/Collaborative Care
What type of
procedure is this?
What are some
post procedure
nursing
care
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interventions?
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Vascular Disorders of the Kidney:
Renal Vein Thrombosis/Occlusion
• Definition:
– partial occlusion in one or both renal veins due to
atherosclerosis or structural abnormalities in vein
by a thrombus
– Risk Factors:
• Nephrotic syndrome
• Use of birth control pills
• Certain malignancies
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Vascular Disorders of the Kidney:
Renal Vein Thrombosis/Occlusion
– Pathophysiology/etiology
• Cause unclear: thrombus forms in renal vein
• Associated with trauma, nephrotic syndrome gradual
deterioration of kidney function
– Common Manifestations/Complications
• Decreased GFR
• Signs of kidney failure
• **Complication ---*_______________
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Vascular Disorders of the Kidney
Renal Vein Thrombosis/Occlusion
• Treatment/Collaborative Care
– Diagnosis- renal venography
– Management
• Thrombolytic drugs
• Anticoagulant therapy
• Surgical thrombectomy
• Cortiocosteroids
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 Definition:
Acute Kidney Injury
(AKI)
(previously known as Acute Renal Failure)
 Rapid decline in renal function- leads to
accumulation of nitrogenous wastes (azotemia)
 Kidneys unable to remove urea from bloodbecome uremic -- aka uremia
(multiple body symptoms affected)
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Acute Kidney Injury
Etiology of AKI:
– Pre-renal
– Intra-renal
– Post renal
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Etiology of Acute Kidney Injury
Pre-renal
Most common cause of pre-renal AKI
• Causes of “pre-renal” AKI
• Hypovolemia: dehydration, shock, burns, N&V, diarrhea
• Decreased cardiac output: CHF, MI, arrythmias
• Dec. vascular resistance (septic shock, etc)
• Renal vascular obstruction: renal artery
stenosis, thrombus
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Etiology of Acute Kidney Injury:
Intra-renal
• Direct injury to the kidneys/nephrons
– causing damage to renal tissue (parenchyma)
– ATN (acute tubular necrosis)
• *Destruction of tubular epithelial cells, slough, plug tubules- abrupt
decline in renal function-recovery possible if basement membrane remains
intact & tubular epithelium regenerates
• Most common cause of Intra-renal AKI
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Etiology of Acute Kidney Injury:
Intra-renal
• Hemolytic blood transfusion (ATN)
• Trauma (crush injuries > release myoglobin>damage
muscle tissue > blocks tubules) (rhabdomylosis)
(ATN)
• Nephrotoxic drugs/chemicals (ATN)
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Aminoglycosides*
Radiographic contrast agents
Arsenic, lead, carbons
Drug overdose
• Acute glomerulonephritis/pyelonephritis
• Systemic Lupus
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Etiology of Acute Kidney Injury:
Intra-renal (ATN)
– Renal ischemia
• Destruction tubular
epithelium
– Nephrotoxic agents
Renal
ischemia
• Necrosis tubular epithelium…
plug tubules.
– Potentially reversible IF
• Basement not destroyed and
tubular epithelium
regenerates
Nephrotoxic
agents
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Etiology of Acute Kidney Injury:
Post-renal
• Causes of “post-renal failure”
– mechanical obstruction of urinary outflow
– urine backs up into renal pelvis
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BPH (Benign Prostatic Hypertrophy)
Calculi
Trauma
Prostate cancer
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Diagnostic Tests:
Acute Kidney Injury
• BUN (blood urea nitrogen)
– Normal = 6-20 mg/dl; measurement of amt of
nitrogen, in the form of urea, in blood
• Serum Creatinine:
– Normal = 0.6 – 1.3 mg/dl
– Directly related to GFR
• 2 X pts. normal = 50% nephron fx loss
• 10 X pts. normal = 90% nephron fx loss
• MORE ACCURATE INDICATOR of kidney function
than BUN
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Diagnostic Tests:
Acute Kidney Injury
• Creatinine clearance
– Most accurate indicator of kidney function
– Reflects GFR (glomerular filtration rate)
– Involves a 24 hr urine/serum creatinine
– Formula:
• urine creatinine X urine volume
serum creatinine
• Normal= 70-135ml/minute
– (+/- 120-125ml/minute)
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Diagnostic Tests:
Acute Kidney Injury
– Urine Specific Gravity
• Normal= 1.003-1.030
• Fixed - 1.010 usually in AKI
– Can indicate ATN
– Kidneys lose ability to concentrate urine
– Serum Electrolyte
• 1. Serum Sodium Normal= 135-145meq/L
– May be high, low, or normal
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Diagnostic Tests:
Acute Kidney Injury
– Serum Electrolytes
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Serum K+
Normal= 3.5-5.0 meq/dL
• Almost always increased in kidney failure
• Why?
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Diagnostic Tests:
Acute Kidney Injury
– Serum Electrolytes
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Serum Calcium
Normal= 8.6-10.2mg/dL
Almost always decreased
Why?
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Diagnostic Tests:
Acute Kidney Injury
– Serum Electrolytes
4.
Serum Phosphorus
Normal= 2.4 - 4.4mg/dL
Almost always increased
Why?
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Diagnostic Tests:
Acute Kidney Injury
– ABGs
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pH
• Metabolic acidosis due to
ability of
kidneys to excrete acid metabolites
(uric acid, ammonia) so the pH will be
__________.
• Also, bicarb levels due to bicarb being
used up to buffer excess H+ ions & ____________
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Stages of Acute Kidney Injury
• Initiating Phase
– Time of insult until signs and symptoms become apparent!
• Oliguric Phase
– Usually appears 1-7 days of initiating event
• Diuretic Phase
– Start varies, usually within10-12 days of onset oliguric phase
• Recovery
– Usually within a month, recovery takes up to 12 months
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Acute Kidney Injury:
Oliguric Phase
 Signs and Symptoms to anticipate?
 Onset: 1-7 days
 Duration: 10-14 days
 Urine output: Less than
400 ml/24 hours in 50%
of patients
 Can have non-oliguric
AKI
 Specific gravity fixed at 1.010 in
oliguria in intra renal failure –
may be elevated in pre & post
 Fluid overload
 Urine with RBCs, casts, WBCs,
protein
(if
glomerulus damaged)
 K+ likely elevated
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Acute Kidney Injury:
Oliguric Phase
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Metabolic acidosis:
kidneys unable to synthesize HCO3, cannot
excrete H+ and acid metabolites; serum
bicarbonate dec. because used to buffer H+
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Ca deficit & phosphate excess:
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Result: Kussmaul breathing
dec. GI absorption Ca (lack of active vitamin D)
Nitrogenous product accumulation:
unable to eliminate urea and creatinine >
elevated BUN, serum creatinine
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Acute Kidney Injury:
Oliguric Phase
Treatment
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Fluid Challenge/Diuretics
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Why do you think it is done?
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Process:
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250-500cc NS given I.V. over 15 minutes
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Mannitol (osmotic diuretic) 25gm I.V. given
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Lasix 80mg I.V. given
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Should see what within 1-2 hours????
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Acute Kidney Injury:
Oliguric Phase
Treatment
If fluid challenge fails, fluid intake is usually limited and
client is placed on fluid restriction
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Restriction is limited to
600ml (includes insensible loss) + UO over the past 24 hours
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Physician will specify in the orders how much
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Acute Kidney Injury:
Diuretic Phase
 Onset: days to weeks
 Duration: about 10 days
(1-3 weeks)
 Urine output: 1-3 liters/day
 Signs and Symptoms to anticipate?
 What happens to fluid volume?
 Elevated BUN and serum
creatinine
 K likely to be elevated or
decreased???
 What happens to urine Na?
 What happens to blood
pressure?
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Acute Kidney Injury:
Recovery Phase
– Onset:
• When BUN and Creatinine
are stabilized
– Duration:
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Signs and Symptoms to anticipate?
– Monitor for signs and
symptoms of F & E
imbalances
• 4-12 months
– Urine output:
• Normal
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– All body systems for effects
of fluid volume changes
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Acute Kidney Injury
Management/Interventions
1- Treat primary disease/condition whether it is
pre-intra-post renal problem.
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2- Prevention:
Frequent monitoring for early signs of AKI in at risk
patients
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Acute Kidney Injury
Management/Interventions
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3- Assess for Fluid V deficit vs Fluid V
overload
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Vital signs – HR, BP, RR
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Strict I & O
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Daily weights 500ml =1lb. (1kg = approx 1000ml)
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Monitor lab value
4- Metabolic Acidosis
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Administer NaHCO3 I.V. as ordered
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Acute Kidney Injury
Management/Interventions
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5- Hyperkalemia
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Give insulin & glucose I.V. or
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Sodium bicarbonate I.V. or
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Calcium gluconate or
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Dialysis or
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Kayexalate po/enema or
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Dietary restrictions
(not necessarily in this order)
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Acute Kidney Injury
Management/Interventions
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6- Calcium Imbalance
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Administer calcium supplements as ordered
7- Treat Hypertension (HTN)
8- Phosphorus Imbalance
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Administer phosphate binders
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*Amphogel *Basaljel, Renagel
Oscal
Phoslo
*Cautious use of aluminum-based phosphate binders
can cause encephalopathy
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Acute Kidney Injury
Management/Interventions
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9- Assess for anemia
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Administer Epogen/Procrit as ordered
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PRBCs as ordered
what do you have to watch for?
10- Diet (nutritional considerations)
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Fluid restriction as ordered
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Low K+ diet, Low Na diet
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Low protein diet why?
11- Emergency Dialysis indicated when
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K+ > 6.0 with s/s, Fluid V overload, uremia
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Metabolic acidosis <15 HCO3
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Acute Kidney Injury
Management/Interventions
• 11a Emergency Dialysis
– Intermittent hemodialysis (HD)
• Used when rapid changes are required
– Continuous Renal Replacement Therapy (CRRT)
• Much slower blood flow rates than HD
• CVVHD
– Continuous venovenous hemodialysis
» Solute loss via convection/diffusion
• CVVH
– Continuous venovenous hemofiltration
» Solute loss via convection (more like mammalian filtration)
» Replacement fluid via hemodilution
• Both use double lumen catheter
CVVH/CVVHD
• When is it indicated?
– acute kidney injury
– pt usually has low blood pressure or other
contraindications to hemodialysis
• Not a treatment for acute hypokalemia
– slow continuous process
– sessions usually last between 12 to 24hrs
– usually performed daily in the ICU