Renal Failure

welcome to the nurse station my name is Maria Mobley and today we are gonna learn about acute kidney injury as always these videos are for educational purposes and I really hope they're helping you feature nurses so a cute kidney injury is very different from chronic renal failure or chronic kidney disease so we'll be on the lookout for a video coming on that but when we're talking about a cute kidney injury we're talking about the kidneys are hurt and a very rapid onset and why I love teaching this content I know I love by my say I love teaching everything in every video but the cause or the trigger to this acute kidney injury really facilitates your critical thinking it really facilitates the assessment that the client is going to present with it's really gonna have facilitate the interventions that you have to know how to do as a nurse so that's what we're really going to focus on a lot so let's first off think about what the kidneys do they do so many things I only drew a picture of one kidney which I'll talk about in one second but kidneys maintain fluid and electrolyte balances they have the ability to excrete electrolytes they have the ability to retain water they have the ability to trigger your wrath system you remember that whole system from a MP renin-angiotensin-aldosterone system don't quote me on that you can google it can't remember the full name acid-base imbalances excretion toxins regulation of blood pressure and erythropoietin is stimulated from the kidneys which helps produce red blood cells in the bone marrow so the kidneys the kidneys do so many things so when we start to have damage to our kidneys this can result in very serious complications and potentially death so as I said before I'm really gonna facilitate your critical thinking to realize hey what triggers the problem what is the onset which we're about our phases in just a second really determines how the clients going to present and really determines your interventions so always remember nursing your nursing process add PI right assessment diagnosis planning intervention or implementation their Universal in evaluation but in these NCLEX style questions they really focus on assessment versus intervention okay so I'll walk you through all of that so I want you to start thinking about the phases of acute kidney injury which there are four and how the client looks in each face all right so phase one is the onset and the onset phase I want you to think what is the cost so every book all your NCLEX resources will break it down into three major causes okay so my drawing over here which I worked really hard on my students can attest that this this is good for me I want you to think about how the kidneys work okay so of course every organ is perfused with the artery that gives it oxygenated blood so it can work so can function so we got our renal artery that's perfusing our kidneys our kidneys right here that the nephron filters and excretes toxins and reabsorbs nutrients or things that we want to keep in our body and then a byproduct of all this is urine so the urine goes from the kidney into the ureter which is attached to your bladder and then your bladder is kind of a storage or reservoir for urine which then eventually the yarn is excreted through their urethra so that's your basic a.m. pee okay so the causes of acute kidney injury could be threefold so I put an A and we're going to talk about each one a look is occurring before it even gets to the kidney so when you think of a cause or a reason for a cute cute kidney injury and this is called a pre renal cause I want you to think decrease per fusion to the kidneys for whatever reason and let's think about it every tissue every cell every everything in our body means oxygen right so if we have decreased perfusion to our kidneys meaning lack of oxygenated blood flow to the kidneys won't that result in problems and there are so many reasons why this can occur I listed a few but think hemorrhage a gunshot victim right there they have a gunshot wound they're hemorrhaging dramatically they have low blood volume little oxygen circulated in their body what are you going to do to cope and I would say we I'm talking like we have the cute kidney injury but we are gonna cope by shunting any little oxygen left to our vital organs our heart lung and brains right kidneys are vital I know but in this life-threatening moment right here right now if it's between sin and oxygen my kidney verses my heart lung and brains I'm gonna send it to my heart lungs and brains every time okay that's shunting a blood dehydration is very similar and shock same thing if you have low fluid volume or low blood volume where is the oxygenated blood gonna go where's you're gonna body try to shoot it too it's always gonna try to get it to your heart lung and brains cuz that will kill us the quickest if we don't get oxygen to those organs so those are some causes so of pre renal okay so this is one of our on sets or our triggers or our cause pria renal you think lack of oxygen to that kidney lack of perfusion and there's multiple causes whatever cause your instructor gives you you know added into your chart so you can make sure to be most successful in your test the second cause is direct kidney damage so I could it be right here for your intrinsic causes I want you to think that this kidney itself the organ is damaged for one reason or another a bit cost can be nephrotoxic meds remember back to pharmacology em annual glycosides those antibiotics highly nephrotoxic contrast eyes contrast eyes we need kidney function if we're gonna shoot a contrast dye into a client's body if their kidneys can't filter it out that's a problem so those are just a couple examples of medications that can directly damage and hurt the kidneys you need to think about a kidney infection pyelonephritis for example an infection of the kidney itself can absolutely be an intrinsic cost and I also put here a see Mia you got to think if we have decreased blood flow due to a pre renal cause and that causes ischemia or damaged cells and tissues and our kidneys our kidneys are not going to be able to function so that could be a cause as well for your entrance that causes for I just want you to think a direct damage to the kidney and then the last thing that can cause or trigger acute kidney injury is post renal so I want you to think everything after the kidneys so your your reader your your bladder in your urethra okay I want you to think if we cannot excrete urine that is gonna backflow up into your kidneys and if the back flows up into your kidneys your kidneys are gonna be damaged very similar to heart failure you know when your heart can't pump effectively where can that pull it back into it can back into your lungs and start to cause respiratory failure so very similar and in Patou okay in terms of the backing up of fluid that leads to damaged so a couple examples that can occur from this is any bladder injury there can be tumors there can be carcinomas there can be cancer for instance in the bladder that can cause a backup of urine we can have an obstruction of our your reader or bladder urethra because of obstruction could be stones okay kidney stones for example another cause of extraction obstruction and I did have to abbreviate a lot on this board just to fit it all in so I'll make sure to always spell out the abbreviations this is abbreviation but I'm prosthetic hyperplasia this is when the prostate for Megan and large so think about where the prostate would be located it would be right behind this jury throw if that gets enlarged can it put pressure on the urethra and you're not be able to escape if that urine can't escape so that we can avoid it isn't it gonna back up to our kidneys and eventually cause post renal acute kidney injury so those are the three types of triggers through three causes think pre renal intrinsic post renal and keep it very basic lack of perfusion perfusion pre renal direct kidney damage so intrinsic factors and then a back up of obstruction of urine so all that urine starts backing up into your kidneys therefore our cause and damage okay that's your post renal causes so those are our causes for acute kidney injury this is going to directly facilitate client assessment and directly facilitate our nursing interventions or nursing actions for the care of these clients so our second phase is called the on your face so when you think about Algeria or anuria right decrease your own production to minimal or absent urine production so always keep in the back here mine what do we need to say that we have healthy urination or we don't have to intervene for urine production they need 30 ml z urine per hour we need to be ensuring that they have 30 ml of urine power that's just one little medicine cup if you think about it to state that they have appropriate urination well in this phase they are not meeting that criteria they are not meeting the 30 ml per hour requirements that we need a state to say we have healthy kidney function so there's a decrease in urine output for one of these reasons and your signs and symptoms of this phase are completely dependent on the cause I'll give you first example signs and symptoms in fvo is for fluid volume overload so let's look qasas okay fluid volume overload they are retaining so much fluid that we are now starting to get elevated blood pressure edema tachycardia jugular vein distention that and that that neck vein is sticking out that's jvd jugular vein distension shortness of breath and crackles because now the fluid our heart can't cope with all this fluid that's building up is now starting to back into our lungs well let's think about this sounds a sense of the fluid volume overload think about your pre renal causes if they're hemorrhaging would they present with signs of fluid volume overload absolutely not they present with signs of fluid volume deficit what if they're in shock or dehydrated do they show signs of fluid volume overload absolutely not well we're thinking about signs and symptoms of fluid volume overload I want you to think intrinsic and post renal problems now the fluid is starting to back up the kidneys are starting to fail so you're retaining all your fluid and urine okay that's what I want you to think for fluid volume overload changes the behavior is universal for all causes a B or C they absolutely once we your kidneys a purpose is to excrete toxins once toxins start to build up in the body can't you have confusion can't you have fatigue lethargy a change in behavior okay next side is metabolic acidosis your kidneys is a coping mechanism for acid-base homeostasis remember kidneys have the ability to regulate hydrogen ion which is acid and your hco3 right here which is your bicarbonate your base so kidneys have the ability to help cope in acid-base imbalances well now that your your organ that helps control acid-base imbalances is failing it will result in an acid-base imbalance and the acid-base imbalance you need to look for is metabolic acidosis so if we're acidic remember pH is 7.35 to 7.45 acidic means the pH starts to decrease okay and also if you're in Hasidic state your bicarbonate hco3 which is your base will start to decrease as low as well because in an acidic state your base is low okay so you need to look for metabolic acidosis and then you need to look at your labs certain labs and you probably ask your instructor I'm sure you will need to know electrolyte levels and lab values if you're taking a test on this content but let's think about the labs that show kidney function let's think about the labs that can show if our kidneys are being damaged or hurt or not working appropriately labs that should always pop in our mind is b1 blood urea nitrogen and creatinine okay that they show appropriate kidney function and when we start to have our kidneys fail or damaged for whatever reason those bu and incretin levels will start to go up okay you're globular filtration rate okay think about what your glomerulus I can never say that word right glomerulus I'll Google the pronunciation not that one but think about what it does in your kidneys isn't that what filters isn't that like your filtering agent to reabsorb what we want to keep in our body and to excrete our toxins through our urine well this is showing kidney function and when our kidneys are damaged or hurt or not working appropriately that value will actually go down showing that we are not filtering as well as we were before okay so you'd have a decreased GFR your kidneys excrete potassium the actually majority of how the body excretes potassium is through the urine so if our kidneys are failed little-to-no you're in production in the AL garrett phase aren't we retaining potassium so you can see hyperkalemia in these clients phosphorus is very hard to filter from the body so the kidneys are damaged filter that phosphorus out into the urine so you can see increased phosphorus levels well let's think what is always inversa phosphorus is calcium so when we start getting high levels of phosphorus in the blood you're gonna start to see hypocalcemia because their direct inverses of each other and if you don't know what an inverse means just think once if they are direct inverses when a component goes up the other has to go down so because the kidneys can't filter phosphorus appropriately it starts to build up in the blood calcium which is the inverse of phosphorus so your phosphorus is going up your calcium is gonna go down so look for high phosphorus levels low calcium levels and your sodium sodium is really dependent on the class okay so sodium can absolutely be normal but let's think if it's an intrinsic cause or a post renal cause aren't be retaining all our fluid we can't excrete fluid through our urine so we're starting to retain fluid retain fluid retain fluid what is that fluid or water gonna do to our serum sodium levels is it going to dilute the sodium levels or is it going to concentrate the sodium levels well we have a lot more water right now compared to sodium particles so if we have signs of fluid volume overload we can absolutely have hyponatremia or a low sodium level so with sodium it could be normal or hyponatremic especially if you have that fluid volume overload okay so again presentation depends on what's going on you won't have fluid volume overload symptoms if the kidneys not getting perfusion in the first place if your body is just lacking oxygen and blood flow in general such as hemorrhage shock dehydration okay but change in behavior metabolic acidosis your changes in your labs are pretty universal for any trigger or any cause of acute kidney injury okay so just keep that in the back your mind at the end we're gonna do two and click style questions so you can see based upon our assessment data it will absolutely lutely change what type of nursing intervention are nursing action we're going to do for our clients okay so this is your oligarch phase I need you to understand treatment needs to occur in this phase we are showing signs of a problem okay in the onset phase it happens very quickly you know a couple hours to less than two days but your body might not be physically showing the symptoms yet in the oligarch phase we have physical assessment data where we don't need to gather any more data anymore we need to act as nurses and act quickly so I want you to think treatment needs to be done in the oligarch phase and treatment of course will depend on the problem as well so let's start with decreased perfusion to the kidneys look at all these problems hemorrhage dehydration shock you have fluid volume deficit so if we help the fluid volume deficit problem if we give fluids won't that increase your fluid volume won't that help circulate more oxygen throughout your body and won't it help better profuse the kidneys to try to stop damage so fluids if we're given fluids a lot of times it's related to decreased perfusion of the kidneys the fluid solutions you would want to start with is our isotonic solution so your 0.9% sodium chloride your normal saline we don't want fluid shifts we want to put it right into our circulatory system and we want it to stay there to replace that volume another treatment could be diuretics think about it we have direct kidney damage or we have this buildup of urine and electrolytes diuretics can help promote that diuresis it could help get let's say they're having symptoms of fluid volume overload it could help get those symptoms out okay or I've said symptoms out it could help get the urine and fluid out of their body so whenever we need diuretics for rapid diuresis you need to think your loop diuretics that's your furosemide aka lasix but for the in collection a generic names so your furosemide or your been made in a boom a denied okay aka boom ex but you need to know your generic names other treatment could be devices let's think about it post renal closets we have a prostate obstructing our urethra okay urine can't get past that enlarged prostate what device might we have to place as nurses an indwelling Foley catheter or a Foley catheter right let's say there's a big stone obstructing urine they might need a ureteral stent let's say the stones caught up in the ureter it's stuck there blocking urine which is not backing up into the kidneys causing damage so we might need a device to alleviate obstructions especially in our post renal causes dietician as needed a lot of clients with acute kidney injury can absolutely be at risk for malnutrition you need to be looking at their protein and seeing what the kidneys are doing in terms of filtering protein appropriately or not so dietitian has needed to regulate diet when I talk about chronic kidney disease were really going to go onto diet because that's very important and then treatment of electrolyte and acid-base imbalances as needed let's look at this let's say we started our intervention let's say we had a client that you know was hemorrhaging or a burn client whatever reason and we now have pre renal causes that led to a lack of oxygen to our kidney causing kidney damage and our potassium could be super super high well they might even though they're not diabetic they might get insulin you all remember back to pharmacology insulin has the ability to take potassium from the blood and transit poured it back into the cell to decrease serum potassium levels they might have to get sodium pilot strain aka kayexalate so the medication can bind to the potassium and we can excrete it from our bodies so there might absolutely be treatment for these abnormal electrolyte levels such as hyperkalemia acid baseman balances you're in metabolic acidosis you might need to give them sodium bicarbonate so if you are not understanding metabolic acidosis review the video I have on that it will explain why bicarbonate levels are low it will explain why also acidosis increases potassium levels as well so we might have to give them sodium bicarbonate and then dialysis dialysis is always a treatment option for kidney failure this will never be your first go-to this is if we know our cause we know our trigger the interventions we're doing are not working we might have to dial size them and filter their blood for them using a machine so I have a video on dialysis in the in the future but that's a whole another entity you need to understand as a nurse okay so a lot of different treatment your treatment is dependent on the cost and we better make sure that we're intervening in the oligarchic phase because that's when your symptoms are presenting so once they have their symptoms in the Aligarh phase once we treat them appropriately they start to pop into the diaeresis phase I want you to think diuresis face is the phase of healing it's when the kidney is starting to repair itself it can last for weeks this diuresis phase so that's when a urine output increases as the kidneys start to heal so whatever assessment data you had in the ala Gert phase let's say they had a nephrotoxic med given to them the intrinsic kidney failure and they wouldn't you they had no minimal - no you're not put they started showing all these times of fluid volume overload so they had crackles in their lungs shortness of breath edema weight gain jugular vein distension all those things whatever symptoms pop up in the allegoric face in the diaeresis face we want to see those symptoms resolved so for that client let's say we diurese them rapidly we gave them furosemide you want to see a decrease in weight do you want to see a decrease in edema you want to auscultate clear clear lung sounds that they had crackles in them we should see an increase sure an output we should start to see the symptoms from this phase minimized in your diuresis phase as the kidneys start to heal and the last phase is your recovery phase so this is when the urine returns back to normal I do need you to understand dependent on how the kidneys healed how well the kidneys healed in this phase will result in the outcome in this phase because if they have acute kidney injury it can absolutely lead to chronic kidney chronic renal disease if the kidneys resulted in permanent damage okay so the recovery phase and dependent on how well did the kidneys heal but their urine output should normalize all the assessment data that you gathered in the ala Dirac phase should be normal we should start to have you know our orientation should be back to normal we shouldn't be so weak and lethargic or fatigued okay and something I forgot to talk about the diaeresis phase just because their urine is increasing they're losing a lot of volume they're losing their fluid so there's always a risk of fluid volume deficit in this phase so their diary singing the kidneys are healing the kidneys are coping but really look for signs of fluid volume deficit look to see if their blood pressures going too low heart rates starting to go high look and see if they're having any signs of dehydration because you might have to give them a lot of fluids to sustain them in the diaeresis phase okay so throughout this whole process I know I don't have enough room on this board we're gonna talk about how you diagnose this disorder on the back but you need to think evaluation what do I need to be looking out once I treated my client to ensure that they're not having further problems with our treatment you should be monitoring all lab values everything from buin creatinine GFR all the electrolytes that could have been abnormal the ABG's if they were in metabolic acidosis to see them normalizing you need to be looking at vital signs if they were in fluid volume overload in the oligarch face their blood pressures should start to come down once treatment works you need to be looking at daily weights I know in your anklet style questions that they're so right here right now acute problem daily weight isn't ever your answer it takes too long right it doesn't help us right here right now for assessment data but don't forget daily weights are the most accurate indicator of fluid volume so they were in fluid volume overload in a Dalek York phase let's say we diurese them for our treatment we want to see their weight start to decrease that shows that it's working so vital signs labs and electrolytes your daily weights your general physical assessment of course head-to-toe assessment and we also better be looking about it at their intake and output specifically their yarn output always always monitor their your an output and acute kidney injury those are things you just need to be utilizing for evaluation did our treatment work or did it not okay so remember I told you we're going to do two critical thinking questions but before I get into that I want you to look about how we diagnosed it just so you know when they come in with symptoms of the acute kidney injury to actually diagnose it with that disease or that title that could be done doing a lot of things done utilizing a lot of things so lab values urinalysis ultrasound they can ultrasound it needs to see what's going on a biopsy a lot of times they might have to do a kidney biopsy if they just cannot figure out that intrinsic kidney problems it has direct kidney damage and they don't really know what's going on they might need to get a kidney biopsy to verify the problem so treatment can be most effective so that's just your diagnostic tools for acute kidney injury I could not fit them on the other side of the board just it let you know but now we're going to do these critical thinking questions before you go read it remember your anklet style questions your priority questions anytime you see first best initial most priority that means we can have multiple answers I want you to know we can do every single answer choices to this client we can do these things in the real world and why it's so frustrating these thing click style questions is in the real world we are doing all answer choices all at the same time but that NCLEX needs to understand if you can do one thing and one thing only did you do what would help them the most in this moment in time the best in this moment in time okay so always make sure you follow ad pi a lot of these assessment questions focus on assessment verse intervention if you don't know how to break down and click style questions yet I have a video for you to review it's called I think break down and click style questions it will really help you kind of just go through this process but I'm just gonna do it quickly step one is to identify your topic and underline the type of data that you have and if you can see I have the same exact answer choices for both clients but dependent on their assessment data it's gonna lead to a different answer choice okay so let's read the first one and I had to abbreviate for lack of room always remember in anklet style questions everything will be written out for you an abbreviation would be followed in parentheses so you don't need to worry if you don't understand abbreviation it was just because the lack of room on the board so a client arrives to the emergency department post NB C so they had a motor vehicle collision the nurse inspects I always underline my assessment data the nurse inspects meaning us we are the nursing this question no visible signs of bleed so this is a low blood pressure high heart rate game is cool and clammy urine output is 15 ml in the last hour that is never good now they have an elevated view and incontinent level which is showing kidney problems and a low hemoglobin and hematocrit that is this that's never the appropriate abbreviation but a low hemoglobin hematocrit level there is a lot of assessment data here so you need to start picking apart first off do I need to gather more data remember you never assess you never pick a nursing assessment answer if you have a right here right now problem and to me and I'm reading a lot of right here right now problems so let's start to look at them we have a low blood pressure a high heart rate skin is cool and clammy low your an output elevated B you in and a low in H so if I highlight these components look at it low blood pressure high heart rate cool and clammy skin low urine output in an H and H I'm not gonna worry about this v1 and creatinine right now because let's think about this this is showing a right here right now fluid volume deficit I would've checked if I need to find an intervention answer I have a right here right now circulation problem I need to find a circulation intervention I'm not saying their kidneys aren't hurt their kidneys are hurt look you can tell their kidneys are damaged or hurt because of the low urine output in that elevator beyond and crabman but let's think about it according to Maslow's is kidney damage or right here right now circulation your priority problem for this question mark R or D problem is circulation circulation trunk kidney damage all day and remember it looks like this clients hemorrhaging oh I don't not that I don't care that they don't have signs of bleed but everything else the low HMH the low blood pressure that higher heart rate the corn clammy skin is showing that this client is bleeding so my if I can only do one thing I'm going to find a circulation intervention and remember in in click style questions if it's in the answer choice you already have the physician order to do so so don't wait for a physician order it's it's assumed you have that physician order to do so remember it always has to be in your scope of practice though okay so I will look for circulation intervention this is assessment this is an intervention this is intervention and this is intervention and remember assessments should gather more data which we don't need I know it would be good to know their pulse ox level I know that and it's so frustrating for students because you're right it would be good to know their pulse ox we might need to put them on oxygen but thinking these in click style questions if you assess the pulse ox you're trying to find another problem where you have problems you need to fix already okay so I know I need an intervention answer I can get rid of one now let's see which one is related to circulation more specifically fluid volume deficit so inserting a Foley catheter is for kidneys administering fluids is for circulation administering a diuretic is for kidneys we should if we can only do one thing and one thing only for this client give them fluids okay give them fluids on this end let's look a client with a history of BPH so they got BPH they'll rise to the emergency department the client states I have not peed in 24 hours always always pay attention to client quotation marks the client is telling you their concern yes it's subjective data I know that we cannot act on that alone but they're gearing me towards their problem okay the nurse assesses bladder distension and a bladder scan result of 1200 ml whew that's a lot if you all know what a bladder scan is it's a little non-invasive device we can do as nurses you put a little jelly on their bladder and it almost looks like if you ever had your have you been pregnant and you've assessed a fetal heart tone okay very similar but it kind of scans the bladder from the outside to see how much urine you're holding just so y'all know for instance a post void residual if I pee and I scare my bladder there should not be more than a hundred ml in there the fact that this guy has 1200 ml in the bladder that's more than a liter in his bladder there's a problem so let's look at our problem no pee and we can't act on that data but bladder distinction and 1200 ml Zin their bladder and they also have a history of BPH so there's no need to gather any more data you have enough data right so you can act I was going to check about to act but my problem is urinary obstruction or urinary retention however you want to put it so you need to look for something about urine that's an intervention so this is assessment intervention intervention I mention all the same things get rid of your assessment this is for circulation that's for urine or your kidneys and this is more so for the kidneys so now you can get rid of your circulation answer but let's think about this if we can do one thing on one thing only are you gonna give a diuretic which you cannot prove will get the urine out because we it could be a urinary obstruction or are you physically going to use a device that we know can get urine up okay so your best answer is to insert a Foley catheter into this client to alleviate all that urine that's sitting in their bladder causing elevated bu an increment levels because this is important too but we got to think about why our kidneys are being hurt why are they damaged right now so I really hope this helps you remember acute kidney injury you need to think about what is the onset what is my cost it will determine your assessment data and it will also determine your nursing interventions okay so good luck critical critically thinking make sure if you understood this helped somebody else so we can all be successful all right take care

Channel: Maria Mobley, MSN, BSN, RN

Views: 5,383

Rating: 4.9459457 out of 5

Keywords: Renal Failure, Acute Kidney Injury, AKI, kidney failure, NCLEX prep

Id: oPh6qeig3Qs

Length: 36min 1sec (2161 seconds)

Published: Tue Apr 23 2019