Acute Kidney Injury

and Chronic Kidney

Disease

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?

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

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?

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.

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?

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

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?

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
9

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?

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?

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

11

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?

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?

A. Blood pressure
B. Fluid volume recovery
C. Urine output
D. Cardiac dysrhythmias

13

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?

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?

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.

15

Challenge Question
Before administering sodium polystyrene sulfonate
(Kayexalate) to a patient with hyperkalemia, the nurse
should assess the

16

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

17

28.

The nurse assesses the progress of a client

diagnosed with acute glomerulonephritis. The
nurse is MOST concerned by which finding?

18

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.

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20

Acute Kidney Injury

Etiology and Pathophysiology
Prerenal
Intrarenal
Postrenal

21

1. The nurse determines that a patient with

oliguria has oliguria of intrarenal acute kidney
injury when

22

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.

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RIFLE Classification
Risk
Injury
Failure
Loss
End-stage kidney disease

25

AKI Clinical Manifestations

Oliguric phase

Urinary changes
Fluid volume
Metabolic acidosis
Sodium balance

26

AKI Clinical Manifestations

Oliguric phase

Potassium excess: ECG changes: next

slide
Hematologic disorders
Waste product accumulation
Neurologic disorders

27

ECG Changes in Hyperkalemia

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AKI Clinical Manifestations

Diuretic Phase
5 L/day
Hypovolemia
Hypotension
Hyponatremia
Hypokalemia
Dehydration

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AKI Clinical Manifestations

Recovery Phase
GFR increases
BUN , Cr: plateau, decrease

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Acute Kidney Injury: Diagnostic

Studies

History
Urine output
Serum Cr
UA
Ultrasound
CT
MRI
MRA

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Acute Kidney Injury: Collaborative

Volume status
Fluid restriction (600 + previous 24 hours)
Diuretic therapy
I & O
Hyperkalemia

32

Acute Kidney Injury: Hyperkalemia

Regular Insulin IV
Sodium Bicarbonate
Calcium Gluconate IV
Hemodialysis
Sodium polystyrene sulfonate
Dietary restriction

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Acute Kidney Injury: RRT

indications

Volume overload
Elevated K
Met Acid: HCO3 < 15
BUN > 120
Mental status changes
Pericarditis, pericardial effusion, cardiac
tamponade

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Acute Kidney Injury: Nutritional

therapy

Adequate protein : 0.6 2g/kg/day

Calories: 30 35kcal/kg
Protein 0.8 1.0 g/kg
Potassium restriction
Sodium restriction
Phosphate restriction

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Nursing Management:
Acute Kidney Injury
Nursing Assessment
Nursing Diagnoses
Planning
Nursing Implementation
Health promotion
Acute intervention
Ambulatory and home care
Evaluation

36

Gerontologic Considerations:
Acute Renal Failure
-Dehydration
-Hypotension
- Diuretic therapy
-Aminoglycoside therapy
-Prostatic hyperplasia
-Surgery
-Infection
-Contrast agents

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Chronic Kidney Disease

38

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?

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?
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.

40

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 clients spouse?

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 clients 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.

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Chronic Kidney Disease : Causes

Diabetes 50%
Hypertension 25%
Glomerulonephritis
Cystic diseases
Urological diseases

43

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Chronic Kidney Disease:

Clinical Manifestations
Urinary System

45

Chronic Kidney Disease:

Clinical Manifestations
Metabolic

46

Chronic Kidney Disease:

Clinical Manifestations
Electrolyte & Acid-base Imbalances

47

Chronic Kidney Disease:

Clinical Manifestations
Hematological
Anemia
Bleeding tendencies
Infection

48

Chronic Kidney Disease:

Clinical Manifestations
Cardiovascular

49

Chronic Kidney Disease:

Clinical Manifestations
Respiratory

GI

50

Chronic Kidney Disease:

Clinical Manifestations
Neurological

51

Chronic Kidney Disease:

Clinical Manifestations
Musculoskeletal

52

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Chronic Kidney Disease:

Clinical Manifestations
Integumentary
Reproductive

Psychological

54

Chronic Kidney Disease:

Diagnostic Studies
UA: dipstick:
Protein
Microanalysis: microalbuminuria

RBC, WBC, casts

BUN
Cr
GFR

55

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Chronic Kidney Disease: Collaborative

Care

Drug therapy
Hyperkalemia
Hypertension
CKDmineral and bone disease
Anemia
Dyslipidemia
Complications of drug therapy

57

Chronic Kidney Disease:

Collaborative Care
Nutritional therapy
Protein restriction
Water restriction
Sodium and potassium restriction

58

Nutritional Therapy
Phosphate restriction
1000 mg/day
Foods high in phosphate
Dairy products
Most foods high in phosphate are
also high in protein.

59

Challenge Question
When teaching a patient with chronic kidney
disease about prevention of complications, the
nurse instructs the patient to:

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60

Challenge Question
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.

61

61

Nursing Management:
Chronic Kidney Disease
Nursing Assessment
Nursing Diagnoses

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63

Dialysis
Hemodialysis HD
Peritoneal dialysis PD

64

Peritoneal Dialysis
https://www.youtube.com/watch?v=CDBNmgkIqMs

65

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 clients intake in
milliliters.

66

When implementing care for the patient on

peritoneal dialysis, the nurse recognizes that
dietary needs include an increased amount of

67

When implementing care for the patient on

peritoneal dialysis, the nurse recognizes that
dietary needs include an increased amount of
1.
2.
3.
4.

fat
protein
calories
carbohydrates

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Peritoneal Dialysis
Automated peritoneal dialysis

APD

Continuous ambulatory peritoneal dialysis CAPD

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70

Peritoneal Dialysis

Fig. 47-6. Peritoneal catheter exit site.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of
Elsevier Inc.

71

Peritoneal Dialysis
Dialysis Solutions and Cycles: 4 per day
Exchange
Inflow
Dwell
Drain

72

Peritoneal Dialysis
Complications
Infection: catheter exit site
Peritonitis
Pain
Hernias
Lower back pain
Protein loss

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74

Peritoneal Dialysis
Continuous ambulatory peritoneal dialysis

75

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?

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?

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.

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Hemodialysis
Vascular Access Sites
Arteriovenous fistulas AVF
Arteriovenous grafts AVG

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Hemodialysis

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Hemodialysis
3 days per week: 3 4 hours
Assessment
Weight
BP
Peripheral edema
Lung sounds
Heart sounds
Vascular access
Temp
Skin
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Hemodialysis
Complications:
Hypotension
Muscle cramps
Blood loss
Hepatitis

86

Continuous Renal Replacement

Therapy

87

Kidney Transplantation
Survival rates
Contraindications

Disseminated malignancies
Refractory or untreated cardiac disease
Chronic respiratory failure
Extensive vascular disease
Chronic infection
Unresolved psych disorders

88

Kidney Transplantation
Recipient Selection

Compatible blood type deceased

Blood relatives
Emotionally related living donors
Altruistic living donors

Histocompatibility Studies

89

90

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

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
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.
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Nursing Management:
Kidney Transplant Recipient
Preoperative Care
Postoperative Care
Fluid and electrolyte balance
Infection
Surgery

Immunosuppressive Therapy

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Nursing Management:
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

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