Exam 3 Flashcards
Assessment with renal dysfunction
Labs: creatinine, BUN, CBC, Urinalysis
ask about urinary habits
hypertension, DM, and HF ???
History of UTI, kidney stones, family history
Urinalysis
purpose: evaluate waste product from kidney
measures: color, clarity, –concentration, specific gravity, pH, wbc, nitrate, bacteria, rbc, ketones, glucose
-collected early in morning
24 hour urine collection
purpose: measure creatinine clearance, urea nitrogen, sodium, chloride, calcium, and proteins
-discard the first void, then collect for next 24 hours
-collection restarted if any sample is discarded
-samples are refrigerated or on ice
renal ultrasound
purpose: noninvasive view of internal structures, can assess size of kidney
post- remove gel
renal CT/MRI
purpose: 3 dimensional imaging of organ system, can assess kidney size, cyst, or mass
prep:assess for iodine or shellfish allergy
post: assess kidney function
Voiding Cystourethrogram
purpose: detects urethral or bladder injury after instillation of contrast to provide imaging of bladder and ureters.
pre: informed consent, may require anesthesia
procedure: insert catheter, instill contrast, obtain x ray, remove catheter
post: monitor for UTI first 72 hours, increase fluids, monitor output
XRAY KUB
purpose: visualization of structure and detection of stones, strictures, calcium deposits, or obstructions
Pre-procedure: verify client is not pregnant, remove clothes over the area, remove all jewelry and metal objects
Kidney biopsy
Purpose: removal of a sample of tissue by excision or needle aspiration for
histological examination.
* Pre-procedure: informed consent, coagulation studies, NPO for at least 4
hours, typically local anesthesia, pt must lay prone (procedure is
contraindicated if they cannot lay in this position for extended periods)
* Post-procedure: monitor for bleeding–> high risk b/c kidney is highly
vascularized–> hematuria, H&H, bruising at puncture site
Cystoscopy/cystourethroscopy
Purpose: used to discover bladder wall abnormalities or occlusions of ureter or urethra
* Pre-procedure: NPO, informed consent, laxative or enema for bowel prep night before. May require anesthesia (not always)
* Intra-procedure: Lithotomy position, vitals monitoring
* Post-procedure: monitor urine output and characteristics (may be pink
tinged), irrigation may be necessary if blood clots are present, encourage
increased fluid intake
Lithotripsy
Purpose: to break a stone into smaller fragments
* Pre-procedure: pt must be able to lie flat, assess for dysrhythmia (as this
procedure can cause or worsen existing)
* Intra-procedure: monitor ECG
* Post-procedure: strain urine for stone passage, bruising may occur at site
(expected finding), assist with pain management r/t stone passage
Ureterolithotomy & nephrolithotomy
Percutaneous:
* Purpose: removal of stone through the skin.
* Pre-procedure: NPO, Informed consent, pt must lie prone
(contraindicated if they cannot do so for extended periods)
* Post-Procedure: monitor nephrostomy for drainage and presence of
blood
Open:
* Purpose: for large or impacted stones
* Pre-procedure: NPO, Bowel prep, Informed consent
* Post-procedure: monitor for excess bleeding, maintain fluid intake,
strain urine for passage of additional fragments, teach prevention
measures
Care and nursing interventions for a nephrostomy tube
Monitory amount of drainage and type hourly within the 1st 24 hours
* A decrease in drainage amount and back pain can indicate tube obstruction
or dislodgement
Monitor for nephrostomy leaking
Sterile dressing changes
Tube flushing–> to check patency and dislodge clots
Urinary tract infections
S/S: pain, fatigue, fever, confusion, frequency, urgency, dysuria, nocturia,
hematuria, retention, feeling of incomplete bladder emptying
* Diagnosis: history, physical exam, urinalysis, CBC, cystoscopy if
recurrent
* Tx: antibiotic therapy, phenazopyridine (urinary analgesic), antipyretic,
increased fluid intake, warm sitz bath 2-3 times a week can relieve pain
* Education: full abx course, drink 2-3 L/day, wipe front to back, do not
hold urine, phenazopyridine (urinary analgesic) will turn urine orange
* Labs: urinalysis–>expect positive WBCs, Nitrite, bacteria, leukocyte esterase, casts; Urine culture and sensitivity; CBC-> elevated WBCs
Renal calculi
S/S: flank pain, fluctuating pain (depending on location of stone), oliguria,
anuria, dysuria, hematuria, bladder distention.
* Diagnosis: x-ray KUB, CT KUB, Ultrasound KUB
* Tx: NSAIDs, Antiemetics, Antibiotics, increase fluid intake (to aid in
passing stone and prevent further stone formation), watchful waiting (for
stones to pass), straining of urine
* Education: once stone type has been determined, patient may need to alter
intake of certain foods.
* Calcium: avoid milk and other dairy products
* Oxalate: avoid spinach, black tea, and rhubarb
* Uric Acid: decrease purine intake–> poultry, fish, gravies, red
wines, sardines
* Struvite: typically results after a bacterial infection. Avoid high
phosphate foods (dairy, red or organ meats, whole grains)
* Labs: urinalysis–> rule out infections, may be positive for RBCs,
Hyperkalemia, Hyperphosphatemia
Polycystic Kidney Disease
S/S: weight gain (due to cyst formation and increased kidney size), flank pain, headache (stroke risk r/t hypertension), hematuria, hypertension (r/t decreased kidney perfusion and initiation of the RAAS system), dysuria, nocturia, constipation (enlarged kidney compresses bowels), enlarged abdominal girth (r/t enlargement of kidneys), kidney stones
* Diagnosis: ultrasound, family history/genetic testing
* Tx: blood pressure control (typically with ACEs or ARBs because they
work directly on the RAAS system), pain management (typically acetaminophen and nonpharmacologic interventions), interventions to slow progression of kidney damage (surgical cyst drainage, dialysis, smoking cessation), infection prevention, Pt will inevitably need a kidney transplant (if they live that long)
* Education: importance of diet (decrease sodium intake), importance of smoking cessation (hypertension risk),
* Labs: urinalysis: + proteinuria, + hematuria; decreased GFR; elevated BUN and creatinine levels, fluctuation in sodium level (can be wasted or retained)
Hydronephrosis/Hydroureter
S/S: flank pain, anuria, abdominal asymmetry (may indicate kidney mass),
abdominal tenderness
* Diagnosis: renal ultrasonography (1st choice), UA, CBC, CT or X-Ray
KUB
* Tx: removal or treatment of obstruction–>
nephrolithotomy/ureterolithotomy, cystoscopy, stent placement;
Nephrostomy placement
* Labs: depend on severity and related kidney damage–> if left untreated
kidney damage will result in low GFR, elevated BUN, elevated Creatinine
Pyelonephritis
S/S: UTI symptoms, N/V, recent cystitis or other UTI
* Diagnosis: urinalysis, culture and sensitivity, Imaging (X-ray KUB, CT)
* Tx: antibiotics, increase fluid intake, pain interventions, antipyretic,
* Education: do not hold urine, drink plenty of fluids, wipe front to back,
take full course of abx,
* Labs: BUN may be elevated (but creatinine will not), urinalysis- + WBC,
+ nitrite, + bacteria, cloudy, foul odor
Glomerulonephritis- acute and chronic
Acute: results from excess immune response within the kidney tissues –> onset about 10 days after time of infection
Chronic: do not know cause
S/S: Proteinuria, hematuria, hypertension, edema (especially in the face and hands), Pulmonary edema (dyspnea, shortness of breath, crackles), neck vein distension, weight gain
Diagnosis: can only be officially diagnosed by kidney biopsy
Tx: r/t fluid overload–> diuretics, sodium restriction, water restriction; Antihypertensives, Dialysis, antibiotic therapy
Education: educate on medication, if dialysis is required–> educate on vascular access care and dialysis schedule/routine
Labs: Elevated BUN and creatinine, electrolyte imbalances r/t ineffective filtration, urinalysis: + RBC and protein, decreased GFR (normal: greater than 125 mL/min)
Stages of bone healing
Hematoma formation within 24-72 hours of fracture
Granulation tissue invades hematoma to form fibrocartilage within 3 days-
2 weeks
Fracture site is surrounded by new vascular tissue known as a callus
within 3-6 weeks
Callus is gradually resorbed and transformed into bone within 3-8 weeks
Consolidation and remodeling of bone can continue for up to 1 year after
musculoskeltal assessment
Neurovascular assessment: Pain level/location/frequency, Sensation (presence of paresthesia), Skin temp/color, capillary refill, pulses (presence, strength, equality), movement (should have full ROM)
Musculoskeletal assessment: Range of motion, Gait, Spinal Alignment, Muscle size and symmetry, palpation for muscle tenderness, assessment of strength and equality, Performance of ADLs
PMH: previous traumatic injuries, previous or current illness (diabetes), family history (ex: osteoporosis)
Lifestyle: employment, social history
Open fracture
breaks through skin
closed fracture
break remains in skin
greenstick fracture
bends enough to snap but only cracks on one side
more common in children
sprial fracture
created from twisting motion; fracture line goes around
transverse fracture
complete fracture that runs horizontally across bone
oblique fracture
diagnoally complete break that runs horizontally across bone
compression fracture
from loading force (even gravity can cause these)
ex) trauma, osteoporsis, tumors
comminuted fracture
broken bone that is in multiple pieces
-usually three or more
simple fracture
single line fracture with no other damage
pathologic/spontaneous fracture
occurs when bone structure is weakened by disease
fatigue fracture
fracture caused by repeated stress over time
most common in athletes
impacted fracture
type of fracture that occurs when pressure is at boths sides of the bones causing it to split and broken ends jam together
traction
used to maintain alignment of the bone fragments/pieces.
Used to decrease muscle spasm
skin traction/ buck’s traction
a short-term treatment that uses weights and a pulley system to help realign broken bones in the lower limb
skeletal traction
pins placed into bone
nursing intervention traction/external fixator
Weights are not touching anything (I.e. bed or floor) Ropes are intact (not fraying or thinning)
Pulley systems are intact
Cleanliness of pins: sterile cotton swab with approved antiseptic–> clean from pin base up the pin, use different swab for each pin–> pin care should be completed at least once a shift
Foot pedal is not touching the bed
fractures
S/S: pain, immobility, swelling, ecchymosis (bruising), deformity, muscle
spasm
Dx: X-ray is preferred, MRI shows related soft tissue injury, CT used in pelvic fx
Tx: rest, immobilization, cast, reduction (closed (no surgery) or open (with surgery))
Internal fixation: hardware in the bone
External fixation: hardware in the bone and outside
Nursing Care: PMH (previous break, osteoporosis, meds, age, activity
level), cause of injury, lactose intolerance/dairy allergy (potential for deficient calcium intake), hx of drug or substance abuse, neurovascular assessments, mobility assessments
Education: cast care, external fixation care, diet education (may need to increase calcium intake)
Medication: pain management, calcium supplementation
Labs: ESR (erythrocyte sedimentation rate), C-reactive protein
Both indicate presence of inflammation somewhere in the body
Surgical procedures:
ORIF (open reduction internal fixation): Hardware is inside bone
External Fixation: Hardware is outside–> assess pin sites every 8-
12 hours for s/s of infection
Amputations
May be Elective or traumatic
Elective: surgical removal r/t chronic disease –> more commonly the lower extremities
Traumatic: result of an injury/trauma –> more commonly the upper extremities
Nursing Care:
Physical assessment: Neurovascular assessment
Psychosocial assessment: altered body image, depressed mood,
financial concerns (connect with proper resources including social worker), denial, self-esteem issues
“Assessing ability to cope, identify and acknowledge feelings, help connect with resources”
Medication: pain management, IV CALICTONIN Post-amputation Tx:
Pain management: especially for phantom limb pain
Phantom limb pain: REAL PAIN!!!! More likely to occur if
they had chronic pain in that limb prior to amputation (ex:
diabetic neuropathy)
Proper stretching of area (flexion contracture prevention)
Neuroma removal (tumor of damaged nerve cells typically at the
end of a limb) can reoccur after removal
Carpal tunnel syndrome
Compression of the median nerve from inflammation (can occur in both hands, but more likely in the dominant hand)
Inflammation=swelling –> increased fluid in space–> fluid compresses nerve
S/S: dull ache/discomfort, paresthesia that may extend up the arm, muscle weakness (may have difficulty holding small objects, turning knobs/keys, and doing other fine motor tasks)
Risk factors: repetitive stress (typing, crocheting, tennis, etc.), obesity, pregnancy, joint inflammation
Dx: Phalen’s maneuver: wrist flexion for 1 minute (numbness in hands indicates positive test), Tinel’s sign: repetitive tapping of the transverse ligament (results in paresthesia indicates positive test)
Tx: wrist immobilization and NSAIDs, behavior modification (ergonomic typing: hands parallel to each other at table, wrist support), physical therapy, corticosteroid injection, median nerve decompression surgery
Median nerve decompression surgery: post-op wrist immobilizer for 4-6 weeks, no heavy lifting
Sprains
tear or stress on ligament (bone to bone)
strain
tear or stress to tendon ( muscle to bone)
RICE
REST
ICE
COMPRESS
ELEVATE
Sprains/strains
NSAID therapy if not contraindicated
Surgery may be needed for either depending on severity.
Compartment syndrome
Rapid increase in pressure within a muscle compartment (compresses muscle, blood vessels, and nerves)
S/S: 6 P’s–> Pain (out of proportion to injury), Paresthesia, Pallor, Pulselessness, Poikilothermic (decreased temperature in one area–> r/t decreased circulation and swelling), Paralysis
Intervention: immediately notify provider, if cause is known remove it (ex: cast), emergency fasciotomy
DVT/PE
S/S: unilateral pain, swelling, redness, and warmth; dyspnea; chest pain;
tachypnea
Medication therapy–> anticoagulants, preventative measures
(compression stockings), bed rest, O2 therapy, thrombolytics, possible
surgery (embolectomy)
Fat embolism
S/S: similar to DVT/PE, if in lung, a petechial rash may appear on the chest (usually the last sign to develop)
Intervention: ABC Maintenace while waiting for fat to be reabsorbed by the body. (Intubation may be required), hydration, fracture immobilization, bedrest
Infection (osteomyelitis)
S/S: Fever (typically greater than 101 Fahrenheit), chills, sweats, elevated
WBC, Bone pain (constant, localized, pulsating, worse with movement), swelling and tenderness
Intervention: intense antimicrobial therapy via IV (for up to 3 months or until infection is eliminated), oral drug therapy may be required after IV, pain management
Complication: loss of function, persistent pain, amputation, death r/t sepsis
Synthetic Fiberglass Cast
More lightweight, strong, dries quickly (within 30 minutes),
can be made water-resistant
Plaster of Paris
Heavy, can take up to 3 days to fully dry, cannot get wet
5 P’s
Pain, Pulse, Pallor, Paresthesia, Paralysis
Nursing interventions for prevention of musculoskeletal problems associated with aging.
Weight bearing exercises for bone strengthening–> slows bone loss
Maintenance of adequate calcium and vitamin D intake (diet or supplementation)
Smoking cessation–> nicotine has been shown to negatively impact
musculoskeletal and immune systems
Maintain regular exercise–> muscle fibers decrease in size and number with age
and can atrophy if unused
Osteopenia (decreased bone density) –> safety through fall prevention is top
priority
Kyphosis (hump-back) –> teach proper body mechanics
Calcium
/t bone strength and muscles–>maintain adequate intake–> (9.0-10.5)
Phosphorous
r/t calcium balance and bone strength–> maintain intake–> inverse
relationship with Ca (Ca increases; P decreases) –> (3.0-4.5)
Vitamin D
r/t calcium and phosphorous absorption–> maintain intake–>
deficiency can result in calcium deficiency
Creatinine Kinase:
can indicate muscle trauma–> recall rhabdomyolysis
Estrogen
timulates osteoblastic activity–> deficient estrogen=weakened bones
LDH and AST
can indicate skeletal muscle trauma
CT Scan
verify pt does not have an allergy to contrast (iodine or shellfish allergies); assess pt’s kidney function prior to contrast as it can be nephrotoxic
MRI
Remove all metal prior to the procedure, verify patient is not pregnant, verify pt does not have a pacemaker, pt must lay supine for up to 1 hour, is the pt claustrophobic
