Exam 3 Flashcards
Function of the kidneys
-BP management
-Fluid balance
-Filtering and excreting waste
-Acid base balance
-Vitamin D is activated in the kidneys (needed to absorb calcium in gut)
characteristics of acute kidney injury
-sudden onset
-May not progress
-Good prognosis
-High mortality if RRT is required or prolonged illness
characteristics of chronic kidney disease
-gradual onset
-progressive to permanent
-prognosis depends
-ESKD fatal without RRT
Three types of AKI
prerenal, intrarenal, postrenal
prerenal AKI cause
Hypoperfusion to the kidneys or diminished bloodflow
-volume depletion, vasodilation, decreased cardiac output
examples of prerenal AKI causes
hemorrhage, low blood volume, poor perfusion, HF, decreased cardiac output, MI, shock, sepsis, dehydration
intrarenal AKI causes
kidney tissue is affected directly; hematological, glomerular, or vascular issue
intrarenal AKI causes examples
acute tubular necrosis (most common), ischemia, nephrotoxic meds/agents(NSAIDs, abx contrast dye), glomerulonephritis, pyelonephritis
postrenal aki causes
obstruction of flow; reverses when obstruction is removed
postrenal AKI causes examples
kidney stones, BPH, cystitis, uti, prostate cancer, bladder cancer, cervical cancer, colon cancer, increased tubular pressure leading to dec GFR
Initiation phase of AKI
time from event to signs of decreased renal perfusion; several hours to two days; potentially reversible
maintenance phase of AKI
BUN and creatinine increased daily, oliguria is common (UOP < 400mL per day), FVO, electrolyte imbalances and acidoses, RRT required
recovery phase of AKI
return of tubular function, 4-6 mo for BUN and creatinine to return to normal, Residual impairment of GFR.
-early dialysis may prevent the traditional diuretic phase of AKI
Assessment findings for AKI
oliguria (dec UOP)
HTN
Edema, FVO
Azotemia
SOB
Confusion
S/S of uremia
S/S dehydration
Bruising
Petechiae
s/s uremia
malaise, fatigue, disorientation, drowsiness
what should you compare with a pt who is admitted with an AKI?
baseline vs current:
Weight
Intake and output
Fluid status
Lab values
lab/diagnostic findings for AKI
-elevated serum creatinine and BUN
-BUN:creatinine ratio may be normal
- creatinine clearance=decreased
-decreased GFR
-inc potassium and sodium and phosphorus
-Dec calcium
-ABG=metabolic acidosis
-Dec H&H
fluids and electrolyte status with AKI
-hyerkalemia (d/t low excretion)
-Hyponatremia (d/t fluid retention)
-hypocalcemia(d/t low excretion)
-hypermagnesemia(d/t low excretion)
-hyperphosphatemia(d/t low excretion)
-hypocalcemia (low excretion of phosphorus, decreased level of vitamin D)
overall interventions for AKI
figure out the underlying cause and treat it!
-maintain BP and normal fluid/electrolyte status(fluids or diuretics)
-AVOID nephrotoxic agents
-nutrition
-dialysis
prerenal AKI management
early recognition is key
-fluids and electrolyte/volume replacement
-caution in those with underlying cardiac disease
-may require inotropes, antidysrhythmic agents, preload/afterload reducers, intraaortic balloon pump
-may require hemodynamic monitoring to guide tx
intrarenal AKI management
treat the infection (acute tubular necrosis, glomerularnephritis, pyelonephritis, etc).
-diet low in protein and restrictions on electrolytes
-balance fluids and electrolytes
-hemodialysis
postrenal AKI management
alleviate the obstruction
-stent may be needed
-lithotripsy
-BPH meds
-stone removal
nutrition therapy for AKI
increased rate of protein breakdown in muscles
-registered dietitian needed to calculate protein and caloric needs
-oral supplements, enteral or parenteral nutrition
-kidney specific formulations
stages of CKD
Stages 1-5
Stage 1 CKD
GFR >90
Abnormal urine findings
Nocturia=first finding
stage 2 of CKD
GFR 60-89
Albuminuria may begin (esp in diabetics)
stage 3 of CKD
GFR 30-59
Azotemia
Albuminuria
stage 4 of CKD
GFR 15-29
Uremia
Discuss RRT
Stage 5 of CKD
GFR <15
RRT or kidney transplant
causes of CKD
HTN, Diabetes, Lupus, rheumatoid arthritis, infections (HIV), Medications (NSAIDs), smoking/tobaacco
most common causes of CKD?
Uncontrolled HTN and diabetes
assessment findings for CKD
Dec UOP(oliguria)
Fluid overload
Electrolyte imbalances
Metabolic acidosis
Anemia
HTN
Edema
Azotemia
Confusion
SOB
complications of CKD
-pericarditis(buildup of waste products)
-HF
-HTN (FVO)
-Hyperlipidemia
-Anemia (Dec EPO)
- cognitive impairments(waste buildup)
-tremor(asterixis)
-uremic symptoms(uremic frost, halitosis, mouth inflammation)
-renal osteodystrophy
uremic symptoms
uremic frost (powdered skin), halitosis , mouth inflammation
halitosis
foul odor, bad breath due to the buildup of toxins in the blood not being filtered out by the kidneys
renal osteodystrophy
cant absorb calcium properly d/t vitamin D not being activated in the kidneys=brittle bones
goal or CKD management
slow the progression and avoid dialysis
interventions for CKD
control the blood glucose and the underlying causes
-lifestyle modifications
-control BP
-control cholesterol
-RRT
-renal transplant
Hemodialysis
the use of diffusion and ultrafiltration cleanses the patient’s blood through a filter
-can be done at bedside in ICU
-pre and post dialysis weight and labs
Hemodialysis details
4 hrs 3 times week via fistula or venous access
-occurs outside the body
-drink less fluids and change diet
What is a fistula?
connects an artery to a vein in your arm, can take up to 3 months to be ready (ATI says 4-6 months)
hemodialysis complications
-volume depletion
-dysrhythmias
-hypoxemia
-disequilibrium syndrome
-vascular access infections
disequilibrium syndrome
caused by the rapid removal of blood urea nitrogen (BUN) during dialysis, which triggers osmotic fluid shifts into the brain. This causes brain cells to swell with fluid, resulting in increased intracranial pressure (ICP).
peritoneal dialysis
-takes a few hours
-each exchange = 20-30 minutes
-peritoneum filled with dialysate solution
-can be done at home
complications of dialysis
-thrombosis of AV access
-Stenosis of AV access
-Infection
-Aneurysms
-Ischemia(fistula blocks blood flow to tissues below site)
-HF
how to aneurysms form as a complication of dialysis
formed from repeated needle punctures and pressure exerted during dialysis
Multiple Sclerosis
Chronic autoimmune, genetic, by infection
-breakdown/destruction of myelin sheath that interferes with electrical impulse transmission
-effects innervation of muscles
-progressive
-young and middle aged adults
-4 types
how many types of MS?
four
MS types
relapsing-remitting, primary progressive, secondary progressive, progressive-relapsing
Relapsing-remitting MS
most common; classic
-vague s/s in beginning and then they go away
-s/s return and may be worse
-eventually leads to secondary progressive
primary progressive MS
symptom onset and progressively gets worse
Secondary progressive MS
no more remission- symptoms progress
progressive- relapsing MS
back and forth, but s/s never fully go away; just severe and less severe
With time=progressively worse
MS is most commonly seen..
in colder climates
In Northern European ancestry
-if someone has a 1st degree relative with it
-onset= 20-50 years old
-women=2-3 times more than men
MS assessment
-numbness and tingling
-“brain fog”
-muscle weakness
-fatigue
-tremors
-dysphagia
-mobility issues
-difficulty speaking
-vision problems
-bowel and bladder dysfunction
-sexual dysfunction
MS psychosocial and cognitive assessment
-depression
-anxiety
-self esteem issues
-short term memory loss
-impaired judgement
-inability to concentrate
MS diagnostics
-CSF: inc protein and WBC
-MRI brain and spinal cord: plaques/lesions, s/s=2 or more areas of brain w/lesions
-Evoked potential testing: transmission of electrical impulses along optic nerve w/ electrodes and flashing lights (VER= visual evoked response)
med Management of MS
Meds- immunomodulators or anti-inflammatory
-marijuana
-improve mobility
-manage cognition
-manage vision changes (diplopia)
MS: avoid…
overexertion
Stress
Extreme temperatures
Extreme humidity
People with infections
Balance rest with activity
SCI
spinal cord injury
spinal cord injury
-complete- entire width of cord
-Incomplete
-1/3 from MVA
-Leading causes: falls, violence, sports-related
-80% young males, mainly Caucasian
most common cervical cord injury
C5
Most common thoracic or lumbar injuries
T12 and L1
Often results in paraplegia
cervical spinal cord injury
Hyperflexion, hyperextension, axial loading or vertical compression, excessive rotation, penetrating
hyperflexion cervical SCI
sudden and forceful movement of head forward
Hyperextension of cervical SCI
sudden and forceful movement of head backwards
Axial loading SCI
compression of spinal cord (vertical= top-bottom)
SCI assessment
-how did it happen-> Hx
-Identify baseline motorsensory
-GCS score (LOC)
-ABC, neuro status
-Perfusion to spinal cord
-mobility and sensory
-GI/GU
-psychosocial
SCI management
-airway
-IVF(prevent shock spinal and neurogenic)
-pressors
-monitor for complications
-immobilization
-prevention of stress ulcers, PPIs, and histamine blockers
thoracic spinal cord injury
lumbar spinal cord injury
autonomic dysreflexia
exaggerated sympathetic nervous response to bowel or bladder stimulation
telltale signs of autonomic dysreflexia
SEVERE HTN
Bradycardia
caused by an issue with bowel or bladder structure or function
S/S autonomic dysreflexia
-SEVERE HTN
-bradycardia
-headache
-nausea
-blurred vision
-sweating
-seizures
-death
causes of autonomic dysreflexia
severe constipation, urinary catheter, bladder overly full, UTI, bowel distension, scrotal compression, hemorrhoids
Tx of autonomic dysreflexia
sitting position (if safe to do so), and assess pt
-treat cause
-monitor BP
-Nifedipine or nitrates
Back pain
-80% of adults
-leading cause of work disability
-lower back: sciatic nerve-burning, stabbing pain down leg or foot
Cervical: burning, stabbing pain down arm, pain in neck, upper back and shoulders, headache
-numbness and tingling
Back pain prevention
proper body mechanics
Weight management
Stretching
Regular exercise
Ask for assistance
Good posture
No high-heels
Ergonomic devices
Avoid nicotine
Adequate calcium and vit D
No prolonged sitting/standing
back pain dx
physical assessment:pain, limited mobility, paresthesia
Imaging: X-ray, CT/MRI, bone scan(perfusion), nerve conduction studies
Ziconotide
CNS depressant for chronic back pain that does not respond to other medications
-black box warning for MH/BH patients bc psychosis is an effect
-given through infusion pump directly into spinal fluid
pt prep for discectomy
pt education for discectomy
indications for discectomy
nursing implications of discectomy
potential complications of discectomy
prioritization of care for discectomy
post-procedure care for discectomy
pt prep for lumbar spinal surgery
pt education for lumbar spinal surgery
indications for lumbar spinal surgery
nursing implications for lumbar spinal surgery
potential complications for lumbar spinal surgery
post-procedure for lumbar spinal surgery
back pain- post surgical care
-CSF leak- halo sign (clear yellow fluid)
-Urinary retention
-Paralytic ilieus
-Fat embolism (bone involvement in surgery(
-Persistent or progressive lumbar radiculopathy (nerve root pain)
-Infection
cholecystitis
Inflammation or infection of the gallbladder
Acute or chronic
-4 F’s and high cholesterol
Four F’s for cholecystitis
female(menopause), fat, forty ,fertile
cholecystitis risk factors
female, fat, forty ,fertile, high cholesterol
function of gallbladder
storage unit for bile (release by liver)
-when we eat, bile released from gallbladder into common bile duct into duodenum (small intestine)
bile components
-bilirubin( from liver. brown, gives stool brown color from old broken down RBCs)
- bile salts(for fat breakdown)
- cholesterol
assessment findings- cholecystitis (acute)
-flatulence
-Dyspepsia
-Eructation(burping)
-Pain-RUQ abd, R shoulder…biliary colic
-N/V
chronic assessment findings- cholecystitis
-jaundice (bilirubin from liver into Small intestine. Stones block common bile duct/biliary tract so swollen that bilirubin can’t leave liver=backup into blood)
-clay colored stools
-icterus(yellowing eyes)
-steatorrhea(fatty stools- bile salts can’t get form liver to SI, fats not absorbed so excreted)
tx for cholecystitis-nonsurgical
-Pain management
-Dissolve/stabilize gallstones-ursodiol and chenodiol
-Lithotripsy
-Percuteaneous transhepatic biliary catheter(relieves pressure and promotes bile flow-drains internally or externally)
surgical tx for cholecystitis
cholecystectomy
-laparoscopic
-snip cystic duct and remove gallbladder
-bile from liver-> common bile duct-> SI
-short recovery time
-less risk infection and complications
nursing care and pt education for cholecystitis
Monitor for bleeding and infection// complications
-low-fat diet education
-s/s bleeding
-s/s infection
pancreatitis
-inflammation or infection of the pancreas
-Acute(rapid and severe) or chronic (vague and slow onset)
S/s pancreatitis
LUQ to midline abd pain, N/V, fever, back pain, extremely painful
Acute pancreatitis symptoms
Epigastric/LUQ pain
-back,flank, shoulder
-relieved by fetal position
Nausea/vomiting
Fever
Jaundice (esp if obstruction - pancreatic swelling)
Cullen’s sign
Turner’s sign
Cullen’s sign
dark bluish discoloration of skin, ascites and around the belly button
-sign of retroperitoneal hemorrhage from pancreas
Turner’s sign
dark bluish discoloration of skin on the side/flank
-retroperitoneal hemorrhage from pancreas
causes of pancreatitis
-alcohol use
-common in men
-younger patients
-inc prevalence during holidays
-gallstones
-ERCP(extension of EGD)(endoscopic retrograde cholangiopancreathography- swelling and inflammation of pancreatic duct)
-trauma
function of the pancreas
-blood sugar control (endocrine function)-insulin and glucagon
-Digestion of CHO, proteins, fats (exocrine function w/ amylase and lipase enzymes)
Complications of pancreatitis
infection
Abscess
Pseudocysts
Diabetes
MODS
ARDS
DIC
Paralytic ileus
types of chronic pancreatitis
chronic calcifying pancreatitis- alcoholism
Chronic obstructive pancreatitis-gallstones
Autoimmune pancreatitis- immunoglobulins attack pancreas
Idiopathic & hereditary chronic pancreatitis- gene mutation
tx for pancreatitis- chronic
nutrition= inc protein and calorie intake
(Significant weight loss and Dec muscle mass)
Pain management
PERT
Dec gastric acid (PPI)
diagnostics for pancreatitis
amylase 3X as normal
Lipase inc
Inc ALT/AST (if blockage)
Inc bilirubin (if blockage)
Inc glucose
Inc CRP(inflammation)
Dec calcium and magnesium
pancreatitis can cause…
type 1 DM
Chronic pancreatitis assessment
pain-not as severe as acute
Ascites-more likely than acute
Steatorrhea- more likely than acute
Jaundice- bilirubin backup in liver
Dark urine-bilirubin backup into kidneys and excreted in urine
S/s DM- pancreas backed up and function Dec=no insulin
nursing care-acute pancreatitis
-NPO diet(rest pancreas)
-IVF(N/V)
-NGT(decompression, N/V)
-electrolyte replacement IV (Ca and Mg)
-PCA Morphine or Hydromorphone
-Dec gastric acid (PPI)
-abx
diagnostics for pancreatitis
CT
Amylase/lipase
Bilirubin
Alkaline phosphatase
Glucose
PERT
pancreatic enzyme replacement therapy
-synthetic pancreatic enzymes in pill/capsule
-take it every time you eat (meal or snack)
pancreatic cancer
-painless jaundice/liver failure
-pale stool
-itching (buildup of bile salts and bilirubin)
-dark urine
-glucose intolerance
-LUQ mass(press on biliary tract)
-poor prognosis
pancreatic cancer tx, pt education, nursing implications
-chemo and radiation
-Pain management
-surgery
Pancreatic cancer surgeries
partial pancreatectomy
Radical pancreatectomy
Whipple procedure
Whipple procedure
remove head of pancreas, duodenum, portion of jejunum, part or all of stomach, and gallbladder
Postoperative pancreatic cancer
-ICU (extended intubation period)
-NPO w/ NGT
-IVF
-biliary drains
-semi-Fowler to Dec abd pressure and WOB
-monitor for: hemorrhage, fluid and electrolyte imbalance and infection
what are the most common risk factors for acute cholecystitis?
Female, fat, forty, fertile, high cholesterol
what are three sign/symptoms of acute cholecystitis
RUQ pain
Nausea/Vomiting
Indigestion
Eructation
Flatulence
name 3 s/s that are more indicative of chronic cholecystitis
steatorrhea, clay colored stools, jaundice, icterus, and dark urine
what changes are expected in the following labs with cholecytitis? (Low, high, or normal)
-WBC
-AST/LDH
-Bilirubin
-Amylase and lipase
-WBC inc
-AST/LDH inc (if blockage)
-bilirubin inc (if blockage)
Amylase and lipase inc (if blockage)
if pt is allergic to IV contrast dye, can they have a HIDA scan?
yes, nuclear imaging doesnt use dye
-radioactive tracer injected into vein and camera takes pictures of tracer as it moves through the body
-tests gallbladder, liver, and bile ducts
-hepatobiliary iminodiacetic acid
3 s/s of pancreatitis
LUQ pain, N/V, steatorrhea, jaundice
what is another name for periumbilical ecchymosis
Cullen’s sign
what are 3 common causes of pancreatitis
alcohol use, gallstones, ERCP
what are 4 interventions for acute pancreatitis
IVF, NPO, electrolytes, pain management, H2 blockers/PPI, abx
what is the name of a complex surgical procedure that includes: remove head of pancreas, duodenum, portion of jejunum, part or all of stomach and gallbladder
Whipple procedure
name 3 prerenal causes of AKI
hemorrhage, burns, dehydration, diarrhea/vomiting, hypovolemia, septic shock, renal artery stenosis
name 3 postrenal causes of AKI
cystitis, cancer, enlarged prostate, kidney stones
What changes are expected in the following labs with acute kidney injury? (low, high, normal, or depends)
-Serum creatinine
-GFR
-pH
-Potassium
-Hemoglobin/hematocrit
-serum creatinine= high
-GFR= low
-pH=low (acidodic)
-potassium=high
-hemoglobin/hematocrit= depends
name 3 interventions for AKI caused by hypovolemia
IVF, blood administration, pressors, electrolyte balance
name 3 interventions of AKI caused by glomerulonephritis
blood cultures, abx, diuretics, antihypertensives, dialysis
what are two most common causes of CKD
Uncontrolled HTN and diabetes
why do pts with CKD become anemic?
no/low EPO production= low RBC production =anemia
name 2 considerations for a pt with an AV fistula for dialysis
Limb alert bracelet
No blood draws
No BP
No IV
Listen for bruit and feel for thrill over fistula
-consider circulation, bleeding, infection
what should the nurse do regarding a pt medication regimen on dialysis days
take all meds as normal except BP meds - consult provider, nephrologist, pharmacist, or dialysis nurse regarding meds
can a pt have an invasive procedure after dialysis on same day? Why/why not?
no, bc pt receives anti coagulation via the dialyzer
name 3 causes of MS
autoimmune, genetic, infection
describe patho of MS
chronic neurologic disease that affects brain and spinal cord due to immune-mediated demyelination and nerve injury; characterized by remissions and exacerbations
what are 2 considerations for a pt suspected of having MS undergoing an MRI?
May have trouble siting still (tremors), no metal allowed, no pacemakers
what is an intervention for a pt with diplopia r/t MS?
eyepatch covering one eye for a few hours and switch
who would the nurse consult if pt with MS has weakness of speech muscles?
SLP (speech language pathologist)
describe hyperflexion that causes spinal cord injury
sudden and forceful movement of the head forward causing extreme flexion of the neck
name 3 ways to prevent spinal cord injuries
dont dive in deep/dark water esp if depth unknown, headrests in car, avoid risk taking, helmets, seatbelts, avoid impaired driving
what med should the nurse consider if pt experiences bradycardia r/t SCI?
atropine
name 2 assessments for nurse to consider if autonomic dysreflexia is suspeted
Assess for bladder distension, UTI, Scott Al compression, constipation, hemorrhoids, temperature, pain
if a SCI pt does not have Morton or sensory response of both lower extremities this is called
paraplegia
