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IU NUR 435 - Exam 5 Study Guide

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Exam 5 Study GuideAcute kidney injury: Acute, rapid loss of renal functionDifferent phases (ie: oliguric phase, initiating phase)Initiating phase• Beginning phase of the insult• Continues until s/s appear• This phase can last for hours to days• Compensatory mechanisms cause an increase in angiotensin II, aldosterone, norepinephrine, and antidiuretic hormone in order to preserve the blood flow to essential organs. • Vasoconstriction occurs along with sodium and water retention• Decreased urine output is accompanied by high specific gravity of urine and a low urine sodium concentration. • If the condition is corrected, the condition is reversibleOliguric phase• Urine output below 400 mL per day• Fixed specific gravity (1.010) and a high sodium concentration (greater than 40) which indicates intrarenal damage that is not responding to compensatory mechanisms of RAAS• Increases in BUN/creatinine, Acidosis, and Fluid overload which are a result of reduced GFR• This phase can last up to 14 days or longer depending on the initiation of definitive treatment (dialysis)Diuretic phase• Occurs when cause of AKI is corrected• Osmotic diuresis (increased urination due to the presence of certain substances in the fluid filtered by the kidneys) which results from high urea levels• Urine output can increase from 1-3L to 3-5L per day• As a result of increased urine output, severe fluid loss can occur which leads to dehydration thus causing electrolyte imbalances• This phase can last 1-3 weeks• As this phase ends, acid/base, electrolytes, BUN, and creatinine levels begin to normalizeRecovery phase• Begins as the kidney begins to return to its regular excretory function• Basement membrane (around the glomerular capillary) is restored and GFR increases • Fluid & electrolyte balance normalizes• This phase can last from several months to 1 yearAssessment: Vitals, urine output, daily weights, breath sounds, peripheral vascular system (edema, JVD). Adequate hydration assessment includes BP, HR, urine output, and clinical signs including quality of pulses, color, temperature, and respiratory statusInterventions: manage fluid balance (carefully administer IVF), administer diuretics, positioning, ambulation, cough & deep breathing, skin care, monitor food intake. Adequate carbohydrates, protein, and fat are necessary components of the diet. Potassium (avoid cardiac complications) and sodium (prevent edema, HTN, and CHF) are strictly regulated. Short term dialysis may be done short term to prevent life-threatening disorders.Medications• Loop diuretics – furosemide, bumetanide (watch for K+ imbalance; if push too quick you can get ringing in your ears)• Osmotic diuretics – mannitol• Nephrotoxic agents (contrast dyes) should be avoided or used with extreme cautionRenal cancerManifestation: Classic triad (flank mass, flank pain, hematuria) , UTI symptoms, HTN, fever, Anemia, Usually asymptomaticManagement: Ultrasound, IVP, Percutaneous needle aspiration, Radical Nephrectomy, and Radiation Assessments• vitals (hypertension can accompany renal cancer)• Pain• Pre-operative assessment – knowledge regarding disease, full system assessment• Post-operative assessment • vitals (hypotension and tachycardia can indicate dehydration, increased temperature can indicate surgical site infection, decreased SpO2 can indicate atelectasis)• I&O (foley)• incision (site, wound care, patency of tubes/catheters)Interventions - Administer pain meds- IV hydration, encourage PO fluids- encourage respiratory exercises (IS, cough & deep breath, position changes)- catheter care (clean away from urethra)- drain/tubes- perform wound care as orderedChronic kidney disease: Progressive, irreversible loss of kidney function Risk factors: hyperlipidemia, smoking, recreational drugs, NSAIDs, glomerulonephritis, lupus, atherosclerosis, polycystic kidney disease (PKD), Diabetes, HTNAssessments: Vitals, Pulmonary, cardiac, and peripheral vascular assessments, Incision – redness, warmth, drainage, Monitor I&OInterventions: Daily weights, restrict fluids & sodium, Administer meds, Cardiac monitor, Skin care, Proper positioning, Renal diet, Immunosuppressive meds (rest of their lives), Pain medsTeaching: o Do not miss dialysis appointments ever* will go into fluid overload o Dietary restrictionso Clinical manifestations CKD and complicationso Avoid nephrotoxic substances (NSAIDs, contrast, nephrotoxic antibodies, and alcohol)Diet Low protein (before dialysis)due to urea nitrogen and creatinine are end products of protein metabolism Low phosphorus  Increased protein (after dialysis)o once dialysis starts, protein can be increased as protein loss is high in dialysiso protein drops and will become fatigue after dialysis; sluggish and dizzy Carbs/fats – needed to minimize the catabolism of body protein and to maintain body weight Water restrictions – based upon urine output and insensible water losses (sweat and respiration)o fluid volume overload due to kidneys not working; not processing the fluids o administer small boluses o diuretics not helpful because they are processed through kidneys  Sodium/potassium restrictions – depend on the ability of the kidneys to excreteo Restricted to 2-4g for eachHemodialysis: blood is separated from a dialysis solution by a semipermeable membrane; uses an artificial membrane• Vascular accesso Double-lumen – placed in subclavian or internal jugular vein; typically used for the short-term o AV fistula – (arteriovenous) – created by surgical anastomosis of an artery and a vein, typically theradial artery and cephalic vein in the nondominant arm The fistula needs to mature in order to become suitable for dialysis Maturing involves the low-pressure vein becomes accustomed to the higher pressures that are generated in the artery The matured fistula appears large, bulging under the skin Can take weeks to months to mature.o AV graft – venous access is created by inserting a prosthetic graft between an artery and vein typically in the nondominant arm. This can be used more quickly but does not last as long It is more prone to infection. o AF fistula & grafts – have a palpable pulsation, a thrill, and a bruit upon auscultation can’t draw blood from the vein meshing these two together • Process o uses diffusion & filtration to remove waste products, electrolytes, and excess water from the body.

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