exam 2 Flashcards
Acute Kidney Injury
Labs Low urine specific gravity High creatinine/BUN High potassium (hyperkalemia) Metabolic acidosis Sometimes you will see: High phosphate Low calcium (hypocalcemia) Low RBC Causes Hypovolemia (volume depletion – burn, hemorrhage, GI lossess) Hypotension (sepsis, shock) Reduced CO and HF Obstruction of kidney or lower urinary tract (renal calculi, emboli, BPH, malignancies, strictures) Bilateral obstruction of the renal arteries or veins (artery stenosis, emboli) Medications (NSAIDS!) IV contrast Trauma Clinical manifestations Appear critically ill Lethargic Dry skin and mucous membranes Edema – legs, ankles, feet Decreased urinary output = oliguria May have CNS symptoms Nursing care Monitoring Fluid and Electrolyte Balance Daily weight Monitor lab levels Assess physical symptoms Monitor intake and output Reducing Metabolic Rate Bed rest may be indicated Monitor fever and infection (increases metabolic rate) Promoting Pulmonary Function Frequent turning, coughing, deep breaths Preventing Infection Avoid indwelling catheters if high risk for UTI Aseptic technique with invasive line Providing Skin Care Bathing in cool water Frequent turning Keep skin clean and well moisturized Trim fingernails Providing Psychosocial Support Family support Clear explanations
Chronic Kidney Disease
Labs for Low GFR Low creatinine clearance High creatinine/BUN Changes in sodium levels Metabolic acidosis Low RBC (anemia) Low calcium (hypocalcemia) High phosphate (Hyperphosphatemia) Causes Uncontrolled high blood glucose Uncontrolled HTN Clinical manifestations Integumentary Bruises Pruritus Dry skin Skin color changes ashen gray to yellowish Dry brittle hair & nails Respiratory Increased respiratory rate Kussmaul respirations Crackles Decreased Po2 Renal Decreased urine output Azotemia Proteinuria Hematuria hyperuricemia Gastrointestinal Anorexia N/V Halitosis Metallic taste in mouth Neurological Peripheral neuropathy Restless legs Change in LOC Lethargy Confusion Encephalopathy Altered motor function Hematological Anemia Weakness Fatigue Pallor Lethargy Bleeding due to impair platelet aggregation Musculoskeletal Renal osteodystrophy Decreased calcium Vitamin D impairment Hyperparathyroidism Pathological fractures Immune Increased risk for infection Cardiovascular High blood pressure Increased HR Dysrhythmias Electrocardiographic changes Abnormal heart sounds Retinopathy Fluid retention w/ peripheral edema and/or pulmonary edema Nursing care Fluid and electrolyte balance Daily weight Intake and output balance Skin turgor and presence of edema Distention of neck veins Blood pressure, pulse rate, and rhythm Respiratory rate and effort Nutritional status Weight changes Laboratory values (serum electrolyte, blood urea nitrogen [BUN], creatinine, protein, transferrin, and iron levels) (see Appendix A on preventing/managing potential complications Hyperkalemia: Monitor serum potassium levels. Notify primary provider if level is at or approaching >5.5 mEq/L, and prepare to treat hyperkalemia. Pericarditis: Assess patient for fever, chest pain, and a pericardial friction rub (signs of pericarditis); if present, notify primary provider. HTN: Monitor and record blood pressure as indicated. Anemia: Monitor red blood cell (RBC) count and hemoglobin and hematocrit levels as indicated. Bone disease & metastatic calcifications: Administer the following medications as prescribed: phosphate binders, calcium supplements, vitamin D supplements.
Nutrition restrictions & modification with kidney disease
Protein Restrictions
Fluid Balance
Intake is 500-600 mL more than the previous day’s 24-hour urine output
Calories mainly from carbohydrates and fats
Vitamin supplementation
Potassium rich foods are monitored
Hemodialysis: Blood, obtained from a vascular access, is filtered through a dialyzer (artificial kidney) and then returned to the patient
low sodium
Normal = Less than 2,300 mg/daily
CKD = Less than 1,500 mg/daily
low potassium
Normal = 3,500 - 4,700 mg/daily
CKD = Less than 2,000 mg/daily
low phosphorus
Normal = 700 mg/daily
CKD = Less than 700 mg/daily
low protein (if not on dialysis) Normal = 0.8 grams of protein per kilogram of body weight CKD (stages 3,4,5) = 0.6 - 0.8 g/kg/day
Vascular access:
Venous catheter
Temporary, short term use
Used ONLY for dialysis
Inserted in subclavian, internal jugular, or femoral vein
Arteriovenous fistula (AVF)
Permanent, best option
Surgically joining artery to vein
2-3 months needed to mature and before it can be used
Pitting edema to AVF site initially post op is normal
Hand exercises encouraged post op
Bruit and Thrill!
Arteriovenous graft (AV graft)
Permanent, used when AVF is not option
Surgically created with graft material between artery and vein
Bruit and Thril!
Peritoneal Dialysis:The peritoneum in the abdomen is used as the membrane through which fluid and dissolved substances are exchanged with the blood
Used when hemodialysis is not an option
Involves infusion, dwell, drain of fluid in the peritoneal space
Important to used warmed fluid – never instill cold fluids
Use sterile technique to prevent infection (peritonitis)
Dialysis Nursing Management:
Promoting Pharmacologic Therapy
Medications are removed from blood during hemodialysis
Dosing and timing may require adjustment
Avoid medication that contain potassium or magnesium
Promoting Nutritional and Fluid Therapy
Dietary restrictions (protein, fluid, sodium, potassium, phosphorus)
Regular education and reinforcement of the diet and lifestyle changes
Meeting Psychosocial Needs
Financial and job problems
Sexual problems/impotence
Depression
Altered body image
Protecting Vascular Access
No blood sticks or blood pressure on extremity
Assess for bruit and thrill
Observe for s/s of infection with vascular access devices
Maintain dressing on the vascular access device
Vascular access devices are used ONLY FOR DIALYSIS!!!!
Monitoring Symptoms of Uremia
Extreme fatigue, cramps in legs, no appetite, headache, nausea, vomiting, trouble concentrating
Detecting Cardiac and Respiratory Complications
Fluid overload, pulmonary edema, heart failure
Pericarditis, which can lead to effusion, which can lead to cardiac tamponade
Controlling Electrolyte Levels and Diet
Daily labs (paying attention to potassium!)
Monitor dietary intake
Managing Discomfort and Pain
Pruritus – antihistamine medications (Benadryl), moisturizing the skin
Pain/neuropathy – analgesic medication, nonpharmacologic measures
Monitoring Blood Pressure
Hypertension is common with kidney disease
Antihypertensive medications must be held before dialysis (due to hypotension)
Preventing Infection
Commonly have low WBC = high risk for infection
ileal conduit
a system of urinary drainage which a surgeon creates using the small intestine after removing the bladder. To do this, the surgeon takes a short segment of the small intestine and places it at an opening he has made on the surface of the abdomen to create a mouth, or stoma.
Nursing Care:
Monitor Intake and Output
May excrete mucous mixed with urine
Providing Stoma and Skin Care
Healthy stoma = pink or red
Stoma is not sensitive to touch, but the skin around it is
Inspect skin for irritation, bleeding, infection
Use skin barrier
A properly fitted appliance is essential to prevent exposure of skin around stoma to urine
Caring for Ostomy
Changing the appliance
Emptying pouch (when 1/3 full)
Controlling odor
Education
Post-op care after kidney surgery
Monitor hemorrhage and shock!
Abdominal distention and paralytic ileus are common
Monitor for s/s of infection
Monitor respiratory status, circulatory status, blood loss
Pain management
Monitor intake/output – drains!
Prevention of DVT/PE
Post- op care after kidney transplant
Assessing for transplant rejection
Oliguria, edema, fever, increasing BP, weight gain, swelling or tenderness over transplanted kidney
Preventing Infection
Monitoring Urinary Function
Addressing Psychological Concerns
Monitoring and Managing Potential Complications
Ischemic Stroke
Vascular occlusion (blood clot/artery stenosis) = no O2 non - modifiable risk factors: Age > 55 Men Ethnicity (african american, hispanic, latino) Modifiable risk factors HTN HLD Smoking Sedentary lifestyle DM A fib Hypercoagulation ETOH Clinical Mans B- balance: dizzy E- eyes: vision changes F- face: droop A- arm: one arm S- speech: slurred, expressive aphasia T-time: call 911! FAST Nursing considerations: CT scan within 25 minutes Give Tpa if pt meets criteria (within 3 hours of onset of symptoms) Keep systolic BP less than 180 & diastolic less than 105 ASK: when were you last normal?
Hemorrhagic stroke
From bleed/hemorrhage, trauma, aneurysm, arteriovenous malformation
Leads to an increased ICP
Non-modifiable risk factors:
Increased age
Ethnicity (AA, hispanic, latino, Japanese)
Modifiable risk factors
HTN
ETOH
Clinical Mans
Change in LOC
Severe HA
N/V or N without V (points to a neuro problem)
Tendonitis
s/s of ischemia
Nursing interventions
Vasospasm
Assess s/s: intensified HA, decreased level of responsiveness, aphasia, partial paralysis
Administer nimodipine
Triple H therapy
Seizures
Initiate seizure precautions
Maintain airway and preventing injury
Administer anticonvulsant medication
Hydrocephalus
Assess s/s: sudden onset of stupor/coma (acute); gradual onset of drowsiness, behavioral changes, ataxic gait (subacute/delayed)
Manage and monitor ventriculoperitoneal shunt
Rebleeding
Assess s/s: sudden severe HA, nausea, vomiting, decreased LOC, neurologic deficit
Confirmed by CT
Manage and monitor HTN with antihypertensives
Hyponatremia
Monitor serum sodium levels
Prompt notification to provider of low levels
Intracranial Pressure
Change in LOC Cushing's triad (hyper, brady, brady) HTN Low HR Slowed breathing Cares: Limit visitors HOB > 30 Avoid bearing down give stool softener & fluids Assess vitals & neuro (NIHSS q1h) Encourage movement/prone position CSF drainage Mannitol Avoid hyper/hypoglycemia Sedation Hypertonic solutions WORRY ABOUT VASOSPASM & SEIZURE
Spinal Cord Injury
Assessment Detailed neurologic exam X-rays CT scan MRI scan for further workup Nursing Interventions Promote breathing & airway clearance •Monitor vital capacity, oxygen saturation, ABGs •Suction, assisted coughing, chest physiotherapy •Breathing exercises •Humidification and hydration •Prevention of pulmonary infections Improve mobility Always maintain proper body alignment Use of specialized rotating bed Frequent repositioning (once safe) Splints to prevent footdrop (AFO) Trochanter rolls ROM exercises Maintain skin integrity Frequent skin assessments Frequent position changes (Q 2H) Keep skin dry and clean Prevention of skin infections Maintaining urinary elimination Urinary retention is common Foley cath initially, but with prompt discontinuation (CAUIT), then intermittent cath Patient/family education on intermittent cath Prevention of UTI Improving bowel function Paralytic ileus is common Monitor/manage NG tube Establish bowel program Administer stool softeners, laxatives, enemas Provide comfort measures: halo traction Manage initial headache Daily pin site care Assessment of skin under vest Education for home care Monitor & manage spasticity, VTE/DVT/PE, orthostatic hypotension
Traumatic Brain Injury
Assessment Level of consciousness Nursing Interventions Monitor ICP: neuro checks Airway: HOB 30 degrees, suction, aspiration precautions, ABGs, ventilator complications Nutrition: supplemental, parenteral, enteral, make sure they get swallow reflex back, check labs DI/SIADH: monitor K, Na, urinary output Seizure precautions Preventing injury: fall precautions Check O2 sat Skin: turn q2h, assess Fluid & electrolytes:treat hypo/hpernatremia Temp: give acetaminophen, use cooling devices (do not let them shiver) Focal Contusion Bruise on brain Change in LOC or loss of it Subdural hematoma Acute RAPID Change in LOC Pupillary change Hemiperesis Poor prognosis Chronic Change in LOC Change in personality HA Resembles a stroke
Diffuse Concussion Change in LOC HA Seizure Vomit Monitor them! Diffuse axonal injury Coma Poor prognosis
Neurogenic Shock
Fight or flight part of brain: sympathetic
Loss of autonomic nervous system function below level of lesion
Usually occurs with injuries above T6
Hemodynamic phenomenon à loss of vasomotor tone
Hypotension
Bradycardia
Decreased cardiac output
Venous pooling in extremities
Peripheral vasodilation
Inability to control temperature
vasoconstriction
Autonomic Dysreflexia
Acute life-threating emergency that occurs in SCI above T6 as a result of exaggerated autonomic responses to stimuli that are harmless in people without SCI
Fight or flight part of brain
s/s
Severe, pounding headache
Paroxysmal hypertension
Bradycardia
Profuse diaphoresis above spinal lesion level
Nausea
Nasal congestion
stimuli/triggers
Distended bladder
Constipation
Stimulation of the skin
Cares
Place patient in sitting position (lower blood pressure)
Rapid assessment to identify and alleviate the cause
Empty bladder immediately, check foley for patency, irrigate or replace
Examine rectum for fecal mass
Examine skin for areas of pressure, irritation, broken skin
Administer antihypertensives
Label medical record/patient chart
