Acute Kidney Injury Chapter 47 Copyright 2014 by

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

ACUTE KIDNEY INJURY § § § Formerly referred to as Acute Renal Failure Changed to encompass entire spectrum of syndrome Stages of AKI (RIFLE criteria- pg. 1166) High mortality rates Characterized by: -Rapid loss of renal function with progressive azotemia (accumulation of nitrogen waste products) -Electrolyte abnormalities (hyperkalemia) AND -Acid/base imbalance Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

AKI ETIOLOGIES Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Etiology and Pathophysiology § Prerenal § Causes are factors external to the kidneys that reduce renal blood flow § Severe dehydration, heart failure, ↓ CO § Decreases glomerular filtration rate § Causes oliguria § Autoregulatory mechanisms attempt to preserve blood flow Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Etiology and Pathophysiology § Intrarenal § Causes include conditions that cause direct damage to kidney tissue § Results from § Prolonged ischemia § Nephrotoxins § Hemoglobin released from hemolyzed RBCs § Myoglobin released from necrotic muscle cells Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Etiology and Pathophysiology § Intrarenal § Acute tubular necrosis (ATN) § Results from ischemia, nephrotoxins, or sepsis § Severe ischemia causes disruption in basement membrane § Nephrotoxic agents cause necrosis of tubular epithelial cells § Potentially reversible Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Etiology and Pathophysiology § Postrenal § Causes include § Benign prostatic hyperplasia § Prostate cancer § Calculi § Trauma § Extrarenal tumors Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock § J. K. is a 37 -year-old man who fell off the roof of a house he was constructing. § He sustained severe lacerations of his face and left leg, with substantial blood loss. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock § Which type of kidney injury is J. K. at risk for? § What are the contributing factors for this? § What signs and symptoms of renal involvement would you assess for? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Clinical Manifestations § RIFLE classification § Risk (R) § Injury (I) § Failure (F) § Loss (L) § End-stage kidney disease (E) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Clinical Manifestations § Oliguric phase § Urinary changes § Urinary output less than 400 m. L/day § Occurs within 1 to 7 days after injury § Lasts 10 to 14 days § Urinalysis may show casts, RBCs, WBCs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Clinical Manifestations § Oliguric phase § Fluid volume § § § Hypovolemia may exacerbate AKI With decreased urine output, fluid retention occurs § § Neck veins distended Bounding pulse Edema Hypertension Fluid overload can lead to heart failure, pulmonary edema, and pericardial and pleural effusions Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Clinical Manifestations § Oliguric phase § Metabolic acidosis § § Serum bicarbonate level decreases Severe acidosis develops § Kussmaul respirations § Sodium balance § § Increased excretion of sodium Hyponatremia can lead to cerebral edema § § Usually asymptomatic ECG changes § Potassium excess Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Clinical Manifestations § Oliguric phase § Hematologic disorders § Leukocytosis § Waste product accumulation § Elevated BUN and serum creatinine levels § Neurologic disorders § Fatigue and difficulty concentrating § Seizures, stupor, coma Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock § J. K. ’s injuries have been repaired, but his urine output has dropped below 350 m. L/day. § J. K. ’s laboratory results reveal BUN 53 mg/d. L and serum creatinine 2. 7 mg/d. L. § He complains of fatigue. § His BP has risen to 178/98. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock § What other manifestations should you observe for? § What other laboratory results should you monitor? § J. K. ’s urine output suddenly increases to 2 L overnight. Is this a positive sign? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury Clinical Manifestations § Diuretic phase § Daily urine output is 1 to 3 L § May reach 5 L or more § Monitor for hyponatremia, hypokalemia, and dehydration § Recovery phase § May take up to 12 months for kidney function to stabilize Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question Which assessment would indicate to the nurse that a patient has oliguria related to an intrarenal acute kidney injury? a. Urinary sodium levels are low. b. The serum creatinine level is normal. c. Oliguria is relieved after fluid replacement. d. Urine testing reveals a specific gravity of 1. 010. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury § Diagnostic studies § Thorough history § Serum creatinine § Urinalysis § Kidney ultrasonography § Renal scan § Computed tomography (CT) scan § Renal biopsy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury § Diagnostic studies § Contraindicated § Magnetic resonance imaging (MRI) § Magnetic resonance angiography (MRA) with gadolinium contrast medium § Nephrogenic systemic fibrosis § Contrast-induced nephropathy (CIN) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock § J. K. ’s urinalysis reveals slight hematuria and a low specific gravity. § Renal ultrasound findings are normal. § What is the overall goal in the management of J. K. at this point? § What nursing interventions would you implement? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury § Collaborative care § Primary goals § Eliminate the cause §

Acute Kidney Injury § Collaborative care § Ensure adequate intravascular volume and cardiac output § Force fluids § Loop diuretics (e. g. , furosemide [Lasix]) § Osmotic diuretics (e. g. , mannitol) § Closely monitor fluid intake during oliguric phase Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury § Collaborative care § Hyperkalemia § Insulin and sodium bicarbonate § Calcium carbonate § Sodium polystyrene sulfonate (Kayexalate) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury § Collaborative care § Indications for renal replacement therapy (RRT) § Volume overload § Elevated serum potassium level § Metabolic acidosis § BUN level higher than 120 mg/d. L (43 mmol/L) § Significant change in mental status § Pericarditis, pericardial effusion, or cardiac tamponade Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury § Collaborative care § Renal replacement therapy (RRT) § Peritoneal dialysis (PD) § Intermittent hemodialysis (HD) § Continuous renal replacement therapy (CRRT) § Cannulation of artery and vein Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury § Collaborative care § Nutritional therapy § Maintain adequate caloric intake § Restrict sodium § Increase dietary fat § Enteral nutrition Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock § J. K. continues to improve, but he has lost 6 lb since admission. § He expresses concern regarding maintaining muscle mass and his ability to perform his job as a construction worker after discharge. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing assessment § Measure vital signs § Measure fluid intake and output § Examine urine § Assess general appearance § Observe dialysis access site Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing assessment § Mental status and level of consciousness § Oral mucosa § Lung sounds § Heart rhythm § Laboratory values § Diagnostic test results Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing diagnoses § Excess fluid volume § Risk for infection § Fatigue § Anxiety § Potential complication: dysrhythmia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Planning § The patient with AKI will § Completely recover without any loss of kidney function § Maintain normal fluid and electrolyte balance § Have decreased anxiety § Comply with and understand the need for careful follow-up care Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing implementation § Health promotion § Identify and monitor populations at high risk § Control exposure to nephrotoxic drugs and industrial chemicals § Prevent prolonged episodes of hypotension and hypovolemia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing implementation § Health promotion § Monitor intake and output § Monitor electrolyte balance § Measure daily weight § Replace significant fluid losses § Provide aggressive diuretic therapy for fluid overload § Use nephrotoxic drugs sparingly Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing implementation § Acute intervention § § § § Accurate intake and output measurements Daily weights Assessment for signs of hypervolemia or hypovolemia Meticulous aseptic technique Careful administration of nephrotoxic drugs Skin care measures Mouth care Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock § J. K. progresses well and is preparing for discharge. § His BUN is 19 mg/d. L, serum creatinine is 1. 4 mg/d. L, and urinalysis is normal. § J. K. has gained 2 lb since his nutritional needs were addressed. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing implementation § Ambulatory and home care § Regulate protein and potassium intake § Follow-up care § Teaching § Appropriate referrals Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management Acute Kidney Injury § Nursing implementation § Evaluation § The expected outcomes are that the patient with AKI will § Regain and maintain normal fluid and electrolyte balance § Comply with the treatment regimen § Experience no untoward complications § Have complete recovery Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Gerontologic Considerations Acute Kidney Injury § More susceptible to AKI § Polypharmacy § Hypotension § Diuretic therapy § Aminoglycoside therapy § Obstructive disorders § Surgery § Infection Copyright © 2014 by Mosby, an imprint of Elsevier Inc.