Exam 3 Flashcards
1
Q
What is HIV?
A
HIV: a chronic and progressive immunodeficiency virus characterized by an attack on CD4 T cells leading to AIDS and death without treatment
2
Q
What are risk factors/transmission methods of HIV? Select all that apply
1) Sharing needles
2) Kissing
3) Sharing a drink
4) Unprotected sex
5) Blood transfusions
6) Breast milk
7) Direct bodily fluid conact
8) Vaginal secretions
9) Sharing utensils
A
1) Sharing needles
4) Unprotected sex (especially anally or with semenal contact)
5) Blood transfusions
6) Breast milk
7) Direct contact with bodily fluids
8) Vaginal secretions
3
Q
What fluid presents the greatest risk in HIV transmission?
A
- Seminal fluid
4
Q
Name each stage of HIV and its signs and symptoms:
A
1) Acute infection: generic viral flu-like symptoms including
- Fever - Sore throat - Night sweats - Chills - Headache - Muscle ache
2) Latent or Chronic infection: feels fine, asymptomatic
3) Acquired Immunodeficiency syndrome (AIDS): Falling WBC count (< 200), individual expriences s/s of opportunistic infections that arise
5
Q
What does the window period refer to in HIV testing? About how many days is it?
Also known as “seroconversion window”
A
Window period: It is the time frame in which there is a high false negative rate because seroconversion, or antibody production is not high enough to be detectable
Days: 0-20 days
6
Q
What labs might be elevated in a patient with HIV? (select all that apply)
1) Sodium
2) WBC
3) Potassium
4) Viral load
A
2) WBC (they are experiencing an infection)
4) Viral load (they should have none without an infection, but they have HIV)
7
Q
What 4 labs are primarily examined during an HIV infection?
A
1) Lymphocyte count (decreased)
2) CD4+ count (decreased)
3) Viral load testing (stage 2, increasing)
4) WBC (increased)
8
Q
What are some opportunistic infections that someone experiencing late stage HIV may experience?
A
1) Candida (thrush)
2) Herpes (cold sores or genital)
3) Kaposi’s sarcoma
4) Pneumonia
5) Lymphoma
6) Cytomegalovirus
7) Toxoplasmosis
8) Recurrent UTIs
9
Q
What is required to make an AIDS diagnosis?
A
- Presence of HIV
AND one or more of the two:
1) < 200 CD4+ count
2) Presence of opportunistic infections
10
Q
What is ART stand for and what is it? Why is combination ART therapy used?
A
ART: Antiretroviral therapy which prevents HIV from replication decreasing viral load
Combination therapy: It is used to both decrease viral load and increase immunity, you need one medication for each.
11
Q
List one ART medication:
A
- Abacavir
- Biktarvy
- Emtricitabine
12
Q
What are common side effects of ART medications:
A
1) Fatigue
2) Weight loss
3) Weight redistribution
4) Diarrhea
5) High cholesterol
6) Mood changes
7) Nasuea and vomiting
8) Rash
13
Q
As a nurse what recommendations would you provide to a patient with HIV experiencing lack of appetite/weight loss?
A
- Eat frequent, calorie dense, high protein, small means
- Take supplements like vitamins A + E
- Eat easy to swallow foods
14
Q
As a nurse what recommendations would you provide to a patient with HIV experiencing weight redistribution?
A
- Exercise regularly
- Consider the tesamorelin injection (reduces excess fat)
- Metformin for those with diabetes
15
Q
As a nurse what recommendations would you provide to a patient with HIV experiencing diarrhea?
A
- Reduce fatty, spicy, dairy, and high insoluble-fiber foods
- OTC loperamide (antidiarrheal)
- Increase fluid intake
- Keep the perineal area dry
16
Q
As a nurse what recommendations would you provide to a patient with HIV experiencing fatigue or sleep difficulties?
A
- Eat nutritious foods
- Avoid smoking, caffeiene, alcohol, and napping
- Stick to a sleep schedule
- Relax before bed
17
Q
As a nurse what recommendations would you provide to a patient with HIV experiencing high cholesterol?
A
- Regular exercise
- Avoid smoking
- Reduce fat intake
- Increase omega-3 fatty acids
18
Q
As a nurse what recommendations would you provide to a patient with HIV experiencing nausea and vomiting?
A
- Eat smaller, more frequent meals
- Eat plain foods (crackers, rice)
- Avoid fatty and spicy foods
- Eat cold meals over hot
- Consider antiemetic prescription
19
Q
As a nurse what recommendations would you provide to a patient with HIV experiencing imapired skin integrity?
A
- ART therapy to prevent Kaposi’s sarvoma
- Keep weeping lesions dressed
- Take analgesics
- Keep skin dry
- Take valcyclovir to reduce/prevent herpes lesions
20
Q
How often should invididuals with HIV on ART be tested for drug efficacy?
A
- Q4-6 weeks for efficacy due to drug mutation or resistance (mainly when changing medications or starting new ones)
21
Q
How often should a patient receive viral load testing to prevent opportunistic infections?
A
- Q4-6 months
22
Q
A
23
Q
What are 6 ways to prevent opportunistic infections in those with HIV?
A
1) Frequent handwashing
2) Get tested for TB
3) Receive yealy influenza vaccine
4) Don’t drink standing water
5) Viral load testing Q4-6 months
6) Take antivirals as ordered
24
Q
What are risk factors for opportunistic infections in those with HIV?
A
1) Stopping ART therapy
2) History of HIV
3) Low CD4+ cell count
25
How often should vital signs and IV site checks take place for patients with HIV?
- Q4H
26
Are nurses allowed to refuse care to patient's with HIV that they have been assigned to?
No, they are not allowed to refuse care unless they have found an appropriate replacement for care and their refusal is based on religious beliefs
27
Which opportunistic infection is foscarnet sodium used to treat and what are two things you need to do when administering it?
**1)** Foscarnet sodium treats cytomegalovirus
**2)** It should be placed on an infusion pump to administer because it needs to be infused slowly
**3)** It is highly toxic to the kidneys thus serum creatinine levels need to be monitored
28
What is PrEP? How effective is it?
- It is preexposure prophylaxis to prevent HIV
- 99% effective in reducing infection of HIV by sex
29
What is PEP? When must it be started by?
- Postexposure prophylaxis that is used after known or possible exposure to HIV
- Must be **started within 72 hours (3 days)**
30
What is the initial lab testing for HIV?
1) Point-of-care testing
2) Western blot
3) HIV antigen/antibody combination assay
4) Chemiluminescent immunoassay
**4)** Chemiluminescent immunoassay is the initial lab test for HIV
- Another test is done using Western Blot or point-of-care testing to confirm infection
31
What education should the nurse provide to patients with HIV to avoid infection?
**1)** Wash hands frequently
**2)** Do not dig in the dirt, no houseplants
**3)** Report any infections or low-grade fevers
**4) Do not share any razors, toothbrushes, washcloths, toothpaste or deodarant**
**5)** Replace toothbrushes after illness
**6)** Do not eat undercooked or raw food
**7)** Do not change pet litter boxes
**8)** Avoid reptiles/turtles
32
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is being admitted to the hospital for treatment of a Pneumocystis jiroveci respiratory infection. Which intervention would the nurse include when creating the plan of care to assist in maintaining the comfort of this client?
1. Monitoring for bloody sputum
2. Evaluating arterial blood gas results
3. Keeping the head of the bed elevated
4. Assessing respiratory rate, rhythm, depth, and breath sounds
**3)** Keep the head of the bed elevated
33
The nurse assesses the client diagnosed with acquired immunodeficiency syndrome (AIDS) for early signs of Kaposi’s sarcoma. What characteristics would be consistent with that lesion? Select all that apply.
1. Flat
2. Raised
3. Light blue in color
4. Resembling a blister
5. Brownish and scaly in appearance
6. Color varies from pink to dark violet or black
**1)** Flat
**6)** Color varies from pink to dark violet or black
34
A client diagnosed with acquired immunodeficiency syndrome (AIDS) gets recurrent Candida infections of the mouth (thrush). The nurse has given the client instructions to minimize the occurrence of thrush and determines that the client understands the instructions if which statement is made by the client?
1. “I should use a mouthwash at least once a week.”
2. “I should use warm saline or water to rinse my mouth.”
3. “I should brush my teeth and rinse my mouth once a day.”
4. “Increasing the amount of red meat in my diet will keep this from recurring.”
**2)** “I should use warm saline or water to rinse my mouth.”
35
How does COVID-19 enter the body?
It binds to ACE-2 receptors found in vascular endothelium
36
Which organs can COVID-19 effect?
**1)** Lungs
**2)** Liver
**3)** Heart
**4)** Brain
**5)** Kidneys
**6)** Intestines
**7)** Pharynx
37
What systemic effects can COVID-19 have?
**1)** Vasoconstriction
**2)** Inflammation
**3)** Hypercoagulability
**4)** Endothelial dysfunction
**5)** Edema
38
What are primary prevention methods for COVID-19?
**1)** Immunization
**2)** Physical distancing
**3)** Handwashing
**4)** Face masks
39
When are you fully vaccinated against COVID-19?
2 weeks following the final dose of the primary series
40
How long does a COVID-19 vaccine provide immunity?
- 6 months+
41
How long after administering the COVID-19 vaccine should you monitor patients for?
Monitor patients for 15 minutes after administration
42
What are risk factors for COVID-19?
**1)** 65+ years old
**2)** Comorbidities (cancer, chronic kidney/liver/lung disease)
**3)** Diabetes
**4)** Heart conditions
**5)** HIV
**6)** Smoking
43
****What are the core signs and symptoms of COVID-19?
**1)** Cough
**2)** Fever
**3)** Chills
**4)** SoB
**5)** Muscle/body aches
**6)** Loss of taste/smell
**7)** Sore throat
**8)** Nausea/vomiting
44
****What are signs and symptoms that a patient's COVID-19 is progressing, indicate an emergency, or require immediate treatment?
**1)** Trobule breathing
**2)** Persistent chest pain/pressure
**3)** New confusion
**4)** Inability to stay awake
**5)** Blue lips
**6)** Tachypnea
**7)** Hypoxemia
**8)** Orthopnea (difficulty breathing while lying down)
**9)** Edema
**10)** Hemoptysis
**11)** Increasing dyspnea or dyspnea at rest
45
****What are the prioties in COVID-19?
**1)** Preventing the spread to others
**2)** Impaired oxygenation
**3)** Preventing severity of symptoms
46
What PPE should be used when treating patients with COVID-19?
**1)** N95
**2)** Eye protection
**3)** Isolation Gown
**4)** Nonsterile gloves
47
What eduction should the nurse provide to patients with COVID-19 to prevent the spread of infection?
**1)** Stay at home
**2)** Wear a mask
**3)** Use a separate bathroom
**4)** Limit caregivers
**5)** Do not share utensils, beddings, or dishes
**6)** Clean used spaces
48
What are ways to promote oxygenation in a patient with COVID-19?
**1)** Reposition and ambulate (as tolerated) frequently
**2)** Change to a stomach-lying (self-proning) position
**3)** Cough and deep breath Q2H
**4)** Increase fluid intake
49
What is the primary method of diagnosing an active COVID-19 infection?
1) Nucleic acid amplification test (NAAT)
2) Point-of-care antigen test
3) Antibody tests (serology)
4) Immunoassay replication
**1)** Nucleic acid amplification test (NAAT)
50
What imaging can be done in COVID-19?
- Chest x-ray for lung infiltrates
51
What is the preferred drug to treat COVID-19? What is its indication, side effects, and education to provide to patients?
**Preferred drug:** Nirmatrelvir-Ritonavir
**Indication:** mild to moderate COVID-19 at risk of pregression to severe infection
**Side effects:** diarrhea + altered taste
**Education:** take missed doses within 8 hours of time, if over 8 skip the dose
52
True or false: Remdesivir is the preferred drug in treating COVID-19
**False:** remdesivir is not the preferred drug, instead it is nirmatrelvir-ritonavir
53
Remdesivir: indication, side effects, monitoring
**Indication:** hospitalized patients with COVID-19 or within 7 days for unhospitalized patients
**Side effects:** hepatotoxicity + nausea
**Monitoring:**
- Hepatic panel
- PT before each administration
- Montior for hypersensitivity during and following administration
54
What types of pneumonia can there be?
**1)** Viral
**2)** Bacterial
**3)** Fungal
55
What is pneumonia?
An infcetion in the lungs that causes inflammation and thick fluid/exudate build up in the alveoli
56
What are risk factors for community acquired pneumonia?
**1)** Older adult
**2)** No pneumococcal, COVID-19, or influenza vaccination
**3) Reduced immunity**
**4)** Tobacco/alcohol use
57
What are risk factors for hospital or ventilator acquired pneumonia?
**1)** Older adult
**2)** Chronic lung disease
**3)** Altered LoC
**4)** Recent aspiration
**5)** Endotracheal/NG tube
**6) Reduced immunity**
- Steroid use, cancer pt., transplant, immunosuppresants
**7)** Mechanical ventilation
**8)** Reduced mobility
**9)** Poor nutrition
**10)** Drugs that increase gastric pH
58
What is more common, community acquired pneumonia or hospital/ventilar acquired?
Community acquired is more common
59
What are systemic signs and symptoms of pneumonia?
**1)** Fever
**2)** Chills
**3)** Malaise
**4)** Loss of appetite
**5)** Myalgias
60
What are pulmonary signs and symptoms of pneumonia?
**1)** Tachypnea
**2)** Dyspnea
**3)** Cough w/ or w/o sputum (bloody possible)
**4)** Labored breathing
**5)** Diminished lung sounds
**6)** Crackles, rhonchi, wheeze
**7)** Low O2
**8)** Diminished chest expansion
**9)** Pleuritic chest pain on inspriation
61
What labs can you check for pneumonia?
**1)** WBC (elevated)
**2)** Sputum
**3)** Blood culture (sepsis)
**4)** ABGs
**5)** Electrolytes (hyponatremia)
**6)** BUN/creatinine
**7)** Check for lactate (sepsis)
62
What imaging can be done in pneumonia?
Chest x-ray, especially for older adults
63
How can pneumonia be prevented?
**1)** Vaccination (influenza, pneumococcal, COVID-19)
**2)** Handwashing
**3)** Avoid crowds and sick people
**4)** Aspiration precautions
**5)** 3L of fluids/day
**6)** Avoid pollutants
**7)** Enough sleep/rest
64
How to prevent hospital acquired pneumonia?
**1)** Pulmonary hygiene (incentive spirometry, CDB, ambulate)
**2)** Hydration
**3)** Oral care (2x/day)
65
How to prevent ventilator associated pneumonia?
**1)** HOB >30
**2)** Oral care
**3)** Hand hygiene
**4)** Sterile suctioning
**5)** DVT prophyaxis
**6)** Daily weaning assessment
**7)** Stress ulcer prophylaxis
66
How can you as a nurse promote gas exchange in those with pneumonia?
**1)** HOB high fowlers
**2)** Early ambulation
**3)** 2-3L/day
**4)** Keep O2 above 90%
**5)** Incentive spirometry
**6)** CDB Q2H
**7)** Bronchidilators
67
How can you as a nurse prevent possible airway obstructions in patients with pneumonia?
**1)** Bronchodilators
**2)** CDB
**3)** Incentive spirometry
**4)** 2-3L/day
**5)** IV steroids
**6)** Expectorants
68
How can you monitor for sepsis in pneumonia?
**1)** Obtain blood cultures
**2)** Administer antiinfectives as prescribed
**3)** Check vitals
**4)** Maintain BP
69
What two medications can be used to support airways in pneumonia? What action do they do and what is the monitoring or side effects of both?
**1)** Albuterol
- **Action:** bronchodilate
- **Side effects:** Tachycardia, tremors
**2)** Steroids - methylprednisolone
- **Action:** anti-inflammatory, prevents swelling
- **Montior:** blood glucose
- **Education:** do not stop abruptly
70
Ceftriaxone: class, action, teaching, SE
**Class:** cephalosporin antibiotic
**Action:** broad spectrum
**Teaching:** complete entire course
**Side effects:** very safe -> allergic reaction + cross sensitivity with penicillins
71
Levofloxacin: class, action, teaching, SE
**Class:** antibiotic, fluoroquinolone
**Action:** broad spectrum
**Teaching:** take with food, avoid sun exposure, complete entire course
**Side effects:** tendon swelling/rupture, c. diff/yeast infection, nausea, vomiting
72
How long within arriving at the ED should antibiotics be given for treating pneumonia?
1) Within 4 hours
2) Within 6 hours
3) Within 1 hour
4) Within 2 hours
**1)** Within 4 hours
73
What are the Systemic Inflammatory Response Syndrome (SIRS) criteria and how many do you need to be diagnosed?
*At least two* of the following to diagnose:
**1)** Temperature of above 100.4F (38C) or below 96.8F (36C)
**2)** Heart rate above 90
**3)** Respiratory rate above 20 or PaCO2 below 32
**4)** WBC above 12,000 or below 4,000
74
What are the requirements for a diagnosis of sepsis?
**1)** SIRS criteria have been met
**2)** Confirmed or suspected infection
75
What two criteria indicate severe sepsis?
**1)** Vasopressors to keep MAP above 65mmHg
**AND**
**2)** Serum lactate above 2mmol/L despite fluid resuscitation
76
77
What indicates septic shock, also known as multiple organ dysfunction syndrome?
Must have SIRS and sepsis AND meet MODS criteria: organ failure and poor clotting with uncontrolled bleeding in two or more organ system
78
What are signs/symptoms of warm and cold shock?
**Warm:** (things are relatively normal)
- Decrease in capillary refill
- Decreased systemic vascular resistance
- Normal to increased cardiac output
- warm extremities
**Cold:**
- Decompensation leading to increased systemic vascular resistance to shunt blood to vital organs
- Decreased cardiac output
- Cold extremities
- Delayed capillary refill
79
True or false: septic shock is nearly irreversible once a patient is in this state
**True**: septic shock, also known as cold shock, is nearly irreversible once a patient is in this state due to multiple organ failure and rapid decline
80
What are risk factors for sepsis?
**1) Patients with reduced immunity (chronic diseases)
2) Patients with lines (especially central lines), tubes, and drains**
**3)** Large open wounds
**4)** Invasive procedures
**5)** Malnutrition
**6)** 80+ y/o
**7)** Diabetes
**8)** CKD
**9)** Hepatitis
**10)** Blood soaked gauze staying in contact for a long period of time
81
What are ways to prevent sepsis?
**1)** Remove any lines, tubes, and drains
**2)** Sterile technique for insertions
**3)** Maintain mucus membranes and skin
**4)** Sepsis screening and assessment to notice changes from baseline (use validated tools like MEWS, qSOFA)
**5)** Wean from ventilator ASAP
**6)** Take temperature 2x/day
**7)** Educate family on s/s of infection
82
What are the cardiovascular signs and symptoms of sepsis?
**Early:** normal to increased HR and BP, increased CO
**Late:** low blood pressure and even more low during septic shock - cytokines keep blood vessels dilated, decreased CO, slow capillary refill
**Disseminated intravascular coagulation (DIC):** widespread hypoxia and ischemia leads to poor clotting as clotting factors are used up for unnecessary clotting
- Low platelets, high INR and aPTT
83
What are the respiratory signs and symptoms of sepsis?
**1)** Increased respiratory rate (tachypnea)
**2)** Low O2 saturation (hypoxia)
**3)** ARDs
84
What are the neurological signs and symptoms of sepsis?
**1)** Restless
**2)** Feels like something is wrong
**3)** Confusion
85
What are the skin (integumentary) signs and symptoms of sepsis?
**Early:** warm and no cyanosis
**Late (septic shock):** cool, clammy, pale skin, mottling, cyanotic, petechia and ecchymosis can occur d/t DIC
86
What are the urinary signs and symptoms of sepsis?
**1)** Low urine output (worsening with shock)
- If they have no reason to have oliguria, suspect shock
**2)** Increased creatinine
87
What are the liver signs and symptoms of sepsis?
**1)** Hyperglycemia, high blood glucose
88
What labs would be examined in sepsis?
**1)** Procalcitonin (high)
**2)** Lactate (>2mmol/L, high)
**3)** WBC (>12 or < 4, high or low with decreasing neutrophils)
**4)** Bacteria in the blood
**5)** Cultures
**6)** Blood glucose (high)
**7)** Late = Low hematocrit, hemoglobin, fibrinogen, and platelets d/t DIC
89
What are the priorities in sepsis?
**1)** Early identification
**2)** Widepsread infection
**3)** Potential for MODs
90
What is the 1-hour protocol for sepsis?
| 5 things
**1)** Lactate levels
**2)** Draw labs/cultures x2 before antibiotics so long as it doesn't delay antibiotics by 45min
**3)** Administer broad spectrum antibiotics
**4)** Rapid administration of 30mL/kg crystalloid fluids for hypotension or lactate >4mmol/L (especially within first 3 hours)
**5)** Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP >65 mmHg
91
What interventions are completed during sepsis?
| 7 things (2 extra)
**1)** Screening for early detection
**2)** O2 therapy, possible mechanical vent
**3)** Antibiotics within 1 hour (cultures before antibiotics)
**4)** Insulin to manage blood glucose **(keep between 140-180)**
**5)** Corticosteroids to manage adrenal insufficiencies
**6)** Heparin therapy for clotting
**7)** Blood replacement for poor clotting **(platelets first choice)**
**8)** Bicarb if pH below 7.2 with AKI
**9)** DVT prophylaxis within 72 hours
92
True or false: Source control to find the infection must be done between 6-12 hours
**True:** source control to find the infection must be done between 6-12 hours to eliminate the infection
93
What is the desired urine output for those who are recovering or recovered from sepsis?
1) >65mmHg
2) >/= 0.1 mL/Kg/Hr
3) >/= 0.5 mL/Kg/Hr
4) < 65mmHg
**3)** >/= 0.5mL/Kg/Hr
94
What is the bundle for preventing Ventilator-associated Infections (VAP)?
| 8 things (2 extra)
**1) HOB 30 degrees**
**2)** Oral care Q12H w/ antimicrobial rinse (mouth ulcer prophylaxis)
**3)** Prevent aspiration
**4)** Subglottic suctioning
**5)** Pulmonary hygiene (turning, positioning, chest physiotherapy)
**6)** Daily assessment for extubation (minimize sedation)
**7)** Maintain cuff pressure (15-20mmHg)
**8) Hand hygiene when caring for ET tube**
**9)** Early ambulation
**10)** DVT prophylaxis
95
You should always assess that patient first when something is going wrong during mechanical ventilation (breathing, color, O2 sat). What does the DOPE acronym mean?
**D:** dislodgement
**O:** obstruction
**P:** pneumothorax
**E:** equipment
96
List some things the nurse should do or know when caring for mechanically ventilated patients:
**1)** Maintain patent airway (assess Q2-4hrs)
**2)** Turn Q2H and assess lung sounds after
**3)** Assess vitals Q4H
**4)** Empty tubing with mositure collection - do not let it go into the humidifier
**5)** Include family when possible
**6)** Moisten oral mucosa Q2-4H
**7)** Move ET tube to opposite side of the mouth Q24H
**8)** Teach patients to avoid valsava maneuvers d/t hypotension (monitor I/Os, weight, urine output)
**9)** Keep TV low w/ moderate PEEP
**10)** Avoid excessive carbs in patients with COPD b/c it increases CO2 production
97
What should blood sugar be kept between during insulin treatment during sepsis?
1) 70-120
2) < 60
3) 120-140
4) 140-180
**4)** 140-180
98
If needing to replace blood after DIC d/t sepsis, what is the first choice?
Platelets are the first choice
99
What are the priorities in cirrhosis?
**1)** Fluid overload - third spacing for ascietes
**2)** Possible hemorrhage d/t GI varices and portal hypertension
**3)** Acute confusion d/t elevated ammonia and hepatic encephalopathy
**4)** Pruritis
100
What is liver cirrhosis?
- Extensive and irreversible scarring of the liver from inflammation and fibrosis
- Scarring and inflammation creates pressure on the liver further damaging the cells and vessels
- Nodules form blocking bile ducts and impair blood flow
- Liver shrinks and becomes hard
101
What are causes of liver cirrhosis?
**1)** Viral hepatitis (hep C)
**2)** Chronic alcoholism
**3)** Chronic biliary obstruction
102
What are complications of liver cirrhosis?
| 8 complications
**1) Portal hypertension:** increased pressure in the portal vein backflowing to the spleen -> splenomegaly, platelet destruction, and **thrombocytopenia (often first sign)**
- Backflows into esophageal veins
- Flows into abdomen too
**2) Ascietes:** fluid shift into the peritoneum from portal hypertension and hypoalbuminemia and esophageal varices (bleed risk)
- Fluid into peritoneum also causes decreased albumin circulation
- Massive ascietes can cause RAAS to activate causing more retention
**3) Biliary obstruction:** cannot absorb vitamin K = bleeding risk and jaundice
**4) Hepatic encephalopathy:** change in mental status, reverisble if caught early, d/t blood shunting from portal vein to central cirulation allowing unprocessed substances (ammonia)
**5) Gastropathy:** slow gastric mucosal bleeding, chronic blood loss anemia
**6) Hepatorenal syndrome:** sudden decrease in urine output, increased BUN + creatinine, increased urine osmolarity
**7) Peritonitis:** bacteria from bowel reach the ascitic fluid causing infection
**8) Hepatopulmonary syndrome:** excesscive asitic volume causing dyspnea d/t increased intraabdominal pressure limiting thoracic expansion + diaphragm function
103
What are signs and symptoms of esophageal varices rupture/bleed?
**1)** Bright red emesis
**2)** Melena (black tarry stool)
**3)** Decreased level of consciosness
**4)** Hypovolemia (**Tachycardia,** hypotension, high RR, low Hgb, low Hct, weak pulses, oliguria, cold)
104
What are early signs and symptoms of cirrhosis?
**Early (vague and nonspecific)**
**1)** Fatigue
**2)** Weight changes
**3)** Anorexia
**4)** Vomiting
**5)** Abdominal and liver pain
**6)** Thrombocytopenia
105
What are late signs and symptoms of cirrhosis?
**1)** GI bleed
**2)** Jaundice
**3)** Ascites
**4)** Spontaneous bleeding
**5)** Dry, itchy skin
**6)** Icterus (jaundice of the eyes)
**7)** Rashes
**8)** Peripheral edema
**9)** Weight gain
**10)** Palmar erythema
**11)** Purpuric lesions/petechiae
**12) Asterixis:** hand flapping
106
What labs are examined during cirrohsis?
**1) ALT (increased)**
**2)** AST (increased)
**3)** Bilirubin (increased)
**4)** Albumin (decreased)
**5)** Prolonged PT/INR
**6)** Ammonia (increased)
**7)** Thrombocytopenia (low platelets)
**8)** Anemia (low Hgb, low Hct, low RBC)
**9)** Hypokalemia (bleeding risk)
107
What diagnostic imaging is used for liver cirrhosis?
**1)** Abdominal x-ray
**2)** CT/MRI
**3)** Ultrasound (ascietes, hepato/splenomegaly)
108
How can you help treat fluid overload in liver cirrohsis?
**1)** Low salt diet **(1-2g)**
**2)** Late stage IV vitamins like thiamine, folate, and a multivitamin
**3)** Diuretics (daily weights, I/Os)
**4)** Paracentsis if respiratory is impacted (have them void before the procedure, vitals and weight before and after)
**5)** Auscultate lungs Q4-8H
**6)** Transjugular intrahepatic portal system shunt (shunt to remove ascietes long term and controls bleeding)
109
What class of medication and medication can help prevent bleeding in liver cirrhosis? Why is it used?
What should you monitor, what are the side effects, and what do you educate patients on?
**- Propranolol (beta-blocker):** helps prevent bleeding by reducing heart rate and hepatic venous pressure gradient
**- Monitor:** blood pressure and heart rate (hypotension and bradycardia) - hold if SBP < 100 or HR is < 60
**- Side effects:** weakness, fatigue, bronchospasm
**- Education:** rise slowly as it may cause orthostatic hypotension
110
What are ways to treat hemorrhage in liver cirrhosis?
**1)** Propranolol (beta-blocker)
**2)** Vasoactive medications like *Octreotide acetate* (suppress gastrin, serotonin, and intestinal peptide decreasing GI blood flow)
**3)** Endoscopy to find and stop the source - endoscopic variceal ligation (banding) to decrease flow
**4)** Pure RBCs, FFP, platelets
**5)** Emergency balloon tamponade
**6)** Antibiotics to prevent infection which can cause bleeding
111
What medication is used to treat confusion in liver cirrhosis? What does it do, what is the goal for this medication, what are the side effects
**- Lactulose:** reduces pH and increases osmotic pressure to draw in water to the intestines, and converts NH3 to NH4, which can be excreted, all of which help *reduce ammonia levels via stool*
**- Goal:** 3 bowel movements per day
**- Side effects:** bloating and cramping
112
What are ways to treat or prevent confusion in liver cirrhosis?
**1)** Minimize hepatoxic medications and medications that are difficult for the liver to metabolize -> Opioids, sedatives, barbituates
**2)** Administer lactulose to excrete ammonia
**3)** Administer nonabsorbable antibiotics to destroy flora decreasing ammonia production -> Neomycin
**4)** Moderate protein low fat diet for high ammonia
113
How can you treat pruritis in liver cirrhosis?
**1)** Moisturizers
**2)** Cool compress
**3)** Corticosteroid creams
**4)** SSRIs
114
What hepatotoxic medications should be avoided in liver cirrhosis?
**1)** Acetaminophen
**2)** NSAIDs
**3)** Alcohol
115
What is pancreatitis?
Autodigestion of the pancreas by enzymes that activate prematurely before reaching the intestines
116
What causes pancreatitis?
Inflammation of the pancreatic duct and obstruction increasing pressure and duct rupture leaading to enzyme release within the pancreas
117
What are risk factors of pancreatitis?
**1) Alcohol consumption (primary risk factor)**
**2)** Biliary tract disease (gallstones can obstruct)
**3)** Hyperlipidemia, hyperparathyroidism, hypercalcemia
**4)** Trauma
**5)** GI surgery
**6)** Kidney failure
118
What are two ways to prevent pancreatitis?
**1)** Avoid excessive alcohol consumption
**2)** Have a low-fat diet
119
What are signs and symptoms of pancreatitis?
**1)** Sudden, severe, knife-like or boring pain
**2)** Pain is in LUQ or epigastric
**3) Pain is worse when lying down**
**4)** Pain relieved by fetal position or upright
**5)** Nausea and vomiting
**6)** Weight loss
**7)** Ecchymosis on flanks and blue-gray periumbilical color
**8)** Jaundice
**9)** Hypoactive bowel sounds
**10)** Ascietes
**11)** Warm, moist, fruity breath (hyperglycemia)
120
What labs would you expect to draw/or to be requested in pacreatitis?
**1) Amylase (increased)**
**2)** WBC (increased)
**3)** Platelets (decreased)
**4)** ALT/AST (increased)
**5)** Ca2+ and Mg2+ (decreased)
**6)** Bilrubin (increased)
**7)** Blood glucose (increased)
**8)** ESR (increased)
121
What are nonpharmacological ways to treat pancreatitis?
**1) NPO until pain free (rest the pancreas)**
**2)** Resume diet with bland, high protein, low fat, non-stimulant foods (no coffee)
**3)** Small, frequent meals
**4)** Side-lying, upright, fetal position, or leaning forward (lying down is more painful)
**5)** No alcohol or smoking
**6)** Antiemetics PRN (nasogastric decompression if bad)
**7)** Limit stress
**8)** Enteral or parenteral nutrition if severe
122
What medication can be used to treat acute pain and mild-moderate pain during pancreatitis? What medication should be avoided?
**1) Acute pain:** morphine or hydromorphone
**2) Mild-moderate pain:** Ketorlac (NSAID)
**3) Avoid:** meperidine b/c of seizure risk
123
What two medications can be used to reduce gastric acid secretion in pancreatitis? What do they do and what should you monitor or do?
**1) Cimetidine:** histamine receptor antagonist to decrease gastric acid secretion
- Give 1 hour before or after antacid
**2) Omeprazole:** proton pump inhibitor to decrease gastric acid secretion
- Monitor for hypomagnesemia
124
What medictation must be used to with meals and snacks for those with pancreatitis? What does it do, moitoring/side effects, education?
**Pancrealipase (Creon):** aids with fat and protein digestion
**- Side effects:** monitor for headaches, cough, dizziness, and sore throat
**- Education:**
- Take with meals and snacks
- Capsule can be opened and sprinkled on non-protein food
- *Drink with a full glass of water after taking*
- Wipe lips and rinse mouth
- Take after histamine/antacid
125
Aside from pain, what is the main complication that pancreatitis can cause and why? How do you treat it?
**Complication:** Hypovolemia d/t extreme fluid shifting from retroperitoneal loss of protein-rich fluids
**Tx:** IV fluids and electrolytes
126
What is a mechanical bowel obstruction?
When the bowel is physically blockes by problems outside the intestines, in the bowel walls, or in the intestinal lumen
127
What is a nonmechanical bowel obstruction?
Known as paralytic ileus or just ileus, a nonmechanical obstruction does not involve a physicl obstruction, instead peristalsis is decreased or absent d/t neuromuscular disturbance causing slowed movement or backup of intestinal contents
128
Why does abdominal distension occur in mechanical and nonmechanical obstructions?
It occurs becuase intestinal contents back up at or above the obstruction. The GI system tries to compensate by increasing peristalsis and increasing secretions, which worsens the block causing edema and capillary leakage into the abdomen d/t the high presure.
129
Where do obstructions occur in the GI system to cause alkalosis and acidosis?
**Alkalosis:** high in the small intestine (vomiting stomach acid and NG suction)
**Acidosis:** End of small intestine or in the large intestines (loss of bicarbonate)
130
Where are obstructions most likely to occur?
1) Duodenum
2) Jejunum
3) Ileum
4) Sigmoid colon
**3)** **ileum** of the small intestine because it is the **smallest, most narrow** location
131
What are causes of mechanical bowel obstruction?
**1) Adhesions** (scar tissue from surgery or pathology)
**2)** Benign or malignant **tumors**
**3)** Appendicitis complications
**4) Fecal impaction** (older adults)
**5)** Strictures d/t Chron's inflammation and radiation therapy
**6) Intussusception:** one piece of bowel folds or telescopes into another segment overlapping
**7) Volvulus:** twisting of the intestine
**8)** Fibrosis d/t endometriosis
132
What are causes of nonmechanical bowel obstructions?
**1) Handling of intestines during surgery**
**2)** Peritonitis d/t leakage of colon contents irritating and inflamming the GI
**3)** Intestinal ischemia d/t arterial or venous thrombosis or embolus decreasing blood flow to or in mesenteric vessels
**4)** Hypokalemia can predispose patients to ileus
133
What are risk factors for bowel obstructions?
**1)** Bowel surgery
**2)** Intestinal tumors/cancer
**3)** Older adults
**4)** Constipation
**5)** Family history of colorectal cancer
134
How can you prevent bowel obstructions?
**1)** 2-3L fluid/day
**2)** Regular exercise
**3)** High fiber diet
**4)** Stool softener PRN (docusate)
**5)** Bulk forming medication (miralax)
**6)** Early detection/screening for colorectal cancer
135
If an obstruction is suspected, what should be the first course of action the nurse should take?
Keep patient NPO and call a provider
136
What are signs and symptoms of a small intestine mechanical obstruction?
**1)** Midabdominal pain/cramping (Straingulation pain is persistent and localized)
**2)** Vomiting, profuse if proximal SI obstruction
**3)** Vomitus with bile and mucus, orange-brown, foul d/t bacteria
**4) Obstipation:** no passage of stool
**5)** No flatus
**6)** Diarrhea in partial obstruction
**7)** Metabolic alkalosis
**8)** Upper abdominal distension
137
What are signs and symptoms of a large intestine mechanical obstruction?
**1)** Mild, intermittent, colicky pain
**2)** Lower abdominal distension
**3) Obstipation:** no passage of stool
**4)** Ribbon-like stool if partial
**5)** Blood in stool
**6) Borborygmi:** high-pitched bowel sounds associated with cramping in early obstruction
**7)** Absent bowel sounds during late stages
**8)** Metabolic acidosis
138
What are signs and symptoms of ileus or nonmechanical bowel obstruction?
**1) Constant, diffuse pain**
**2)** Abdominal distension
**3)** Pain d/t ischemia is severe and constant
**4)** Early decreased bowel sounds and absent later
**5)** Vomiting gastric contents and bile is frequent, **rarely has foul odor like SI mechanical obstruction**
**6)** Obstipation may be present
139
What signs and symptoms might indicate a perforated bowel?
**1)** Severe pain that goes away
**2)** Fever
**3)** Tachycardia
**4)** Hypotension
**5)** Abominal rigidity
Report immediately
140
What labs are examined during a suspected bowel obstruction?
**No definitive labs** but:
**1)** High hemoglobin, hematocrit, and BUN d/t dehydration
**2) Hyponatremia, Hypokalemia, Hypochloremia**
**3)** Increased amylase
141
What is the typical imaging for bowel obstructions?
**1) Abdominal CT**
**2)** Abomdinal x-ray
**3)** Ultrasound (find probable cause)
**4)** Endoscopy (definitive cause)
142
How should bowel obstructions be nonsurgically managed if no strangulation or ischemia?
**1)** Keep NPO
**2)** Insert nasogastric tube for decompression -> low continuous suction
- Monitor proper output and placement Q4H
**3)** IV fluids and electrolyte replacements (mainly sodium and potassium) for all obstructions
**4)** Frequent oral care
**5)** Pain control -> place in semi-fowlers and use analgesics with caution
143
What is the gold standard to confirm nasogastric tube (NGT) placement?
1) CT
2) X-ray
3) Ultrasound
4) MRI
**2)** X-ray is the gold standard
- It's also important try and aspirate some gastric contents to verify location
144
What is the management for complete obstructions? What kind of procedures?
**1)** Complete obstructions: surgical management
**2)** Exploratory open laparotomy or laproscopic surgery (closed)
- Colostomy or even colon resection
- NGT tube inserted until GI motility returns and can withstand some intake
145
What type of ostomy is more irritating to the skin and why?
An **ileostomy is more irritating to the skin** than a colostomy becuase stool is more watery and less formed d/t it's placement in the small intestine
146
Describe an ileostomy: placement, output, stool characteristics, diet to follow, etc.
**1)** At ileum (bypasses entire large intestine)
**2)** Located in RLQ
**3)** Initial output can be up to 2L/day
**4)** Stool: green, odorless, loose
**5)** Diet: low-residue
**6)** Watch for enteric coated medications
147
Describe a colostomy: Placement, stool characteristics, diet to follow
**1)** In the large intestine either right or left
**2)** RLQ or LLQ
**3) Stool:** more formed if lower (LLQ), higher is more liquid (RLQ)
**4) Diet:** Regular
148
What should a healthy stoma look like?
**1)** red/pink
**2)** Moist
**3)** Protrudes 1-3cm
149
What should an immediate postoperative stoma look like?
- Edematous
- Small bleeding is expected
- Stool should come in 2-5 days
150
What does an unhealthy stoma look like?
**1)** Dark red, purple, black
**2)** Dry
**3)** Ischemic
**4)** Heavy bleeding = immediately report to surgeon
151
What should an unhealthy peristomal area look like?
**1)** Redenned
**2)** Moist
**3)** itchy
**4)** Impaired skin integrity
152
How can nurses prevent peristomal breakdown?
**1)** Cleanse the peristomal area with mild soap and water (no alcohol)
**2)** Dry the area before applying a new bag
**3)** Enure a good, secure fit for the bag
**4)** The ostomy bag barrier should be cut 1/8 inch
153
What locations might cause fluid and electrolyte imbalances for ostomies?
- Any locations that are higher up in the GI system (ileostomies and higher colostomies)
154
What foods should individuals with new ostomies avoid to prevent blockages?
**1)** Stringy vegetables
**2)** Popcorn
**3)** Fresh tomatoes
155
What foods should individuals with ostomies avoid that are gas producing?
**1)** Broccoli,
**2)** Cabbage,
**3)** Corn,
**4)** Fish
156
How is a recurrent urinary tract infecetion defined?
2+ infections within 6 months or 3+ in a year
157
What does uncomplicated versus complicated UTI mean?
**Uncomplicated:** no anatomical or functional abnormality of the urinary tract that makes the risk for infection or treatment failure higher
**Complicated:** the presence of an anatomical or functional abormality that increases infection risk or treatment failure (i.e. pregnancy, male sex, obstruction, diabetes, CKD, etc.)
158
What is colonization?
Bacterial presence in the urine or urinary tract but with **NO symptoms**
159
List possible risk factors/contributors to cystitis (UTI):
**1) Reduced immunity**
**2) Female sex**
- Short urethra
- Urethral opening closer to anus
**- Hormonal changes such as menopause and low estrogen**
- Pregnancy
**3)** Male sex
- Prostate enlargement creating stasis
- Loss of prostate proteins with age
**4)** Stones (calculi = obstruction, surface irritation)
**5)** Diabetes (glucose for bacterial and neuropathy = flaccid bladder)
**6)** Concentrated urine
**7)** Recent antibiotic use
**8) Sexual intercourse**
**9) Indwelling foley**
160
What risk factor is the strongest factor contributing to cystitis (UTIs)?
Sexual intercourse
161
What are signs and symptoms of acute complicated cystitis?
| Think of having the flu along with specific tenderness and pain to a UTI
**1)** Fever
**2)** Flank pain
**3)** Chills/rigors
**4)** Malaise
**5)** Costovertebral angle tenderness
**6)** Pelvic pain in women or perineal pain in men
162
What pathogen is responsible for most cystitis (UTIs)? What are other possible pathogens?
**1)** E. coli (80% of infections)
**2)** Candida
**3)** Enterococcus (less common)
**4)** Klebsiella (less common)
163
What are examples of noninfectious cystitis causes?
**1)** Chemical exposure
**2)** Radiation therapy
**3)** Immunity issues like SLE (lupus)
164
What is interstitial cystitis and what are its signs and symptoms?
**Interstitial cystitis:** chronic inflammation of the *entire* urinary tract (bladder, urethra, muscles) that is related to genetic and immunity dysfunction, **NOT infection**
**S/S:**
**1)** Pain with bladder filling and/or voiding
**2)** Increased urinary frequency
**3)** Increased urinary urgency
**4)** Nocturia
**5)** Suprapubic and/or pelvic pain
165
What are the key signs and symptoms of cystitis or urinary tract infections?
**1) Inreased urinary frequency**
**2) Increased urinary urgency**
**3) Dysuria (Burning while voiding)**
**4)** Suprapubic pain
**5)** Nocturia
**6)** Urinary incontinence
**7)** Urinary retention
**8)** Hematuria
**9)** Pyuria (WBC in urine)
**10)** Bacteriuria
**11)** Feeling of incomplete bladder emptying
166
What signs and symptoms might an older adult present with if they have cystitis (UTI)?
**1) Change in mental status - confusion**
**2)** Dysuria
**3)** Urinary incontinence
**4)** Nocturia
**5)** Urgency
**6)** Decreased well-being
167
How might vitals be changed in cystitis or UTI?
**1)** Increased HR
**2)** Low BP
**3)** Increased RR
168
What labs are examined during cystitis (UTI)?
**1)** Urinalysis
- Positive leukocyte esterase and nitrate is sensitive
- Presence of WBCs (pyuria), RBCs, and casts
**2)** Culture (determine bacteria)
**3)** Cystoscopy (for recurrent UTIs and interstitial cystitis)
**4)** CT
169
How do you prevent catheter-associated urinary tract infections (CAUTI)?
**1)** Use sterile technique when inserting catheters
**2)** Hand hygiene
**3)** Only use if necessary
- Perioperative PRN
- Acute retention/obstruction
- Measurement of urine during critical illness or injury
- Palliative
- Wound healing d/t incontinence
**4)** Routine hygiene to clean periurethral area not antiseptic
**5)** Assess need for catheter daily
170
How can you prevent cystitis (UTIs)?
**1)** Drink 2-3L fluids/daily
**2)** Good hand hygiene
**3)** Good sleep, rest, and nutrition for immune health
**4)** Avoid spermicides
**5)** Do not delay urination (Don't hold it)
**6)** Women should clean perineum and empty bladder before and after sexual intercourse
**7)** Wipe from front to back only
**8)** Men should clean perineum before intercourse
171
What is the drug of choice for Candida based cystitis (UTI)?
**Fluconazole** is the drug of choice for Candida infections because it is an antifungal
172
Phenazopyridine: what drug class is it, what does it do, side effects, education
**Class:** antispasmodic/urinary analgesic
**Action:** decreased bladder spasms, promotes bladder emptying, and provides pain relief (it does **NOT** treat the infection)
**Side effects:** turns tears and urine orange to red that may stain clothing
**Education:** Take with food
173
What antibiotic education should you give for those with cystitis (UTIs)?
**1)** Complete full course
**2)** Avoid sun exposure d/t sensitivity
**3)** Report any diarrhea or allergic reaction symptoms
174
What non-pharmacological methods can be used to treat cystits (UTIs)?
**1)** Warm sitz bath 3x/day for 20 minutes
**2)** Increase fluid intake to atleast 1.5L
**3)** Drink cranberry juice is it can reduce bacteral ability to adhere to cells
- avoid in intersitial cystitis
**4)** Avoid spices, soy products, and tomato products to reduce irritation and pain
175
What is hemodialysis and when is it indicated?
**Hemodialysis:** is the processes of a machine filtering the blood to remove excess fluid, eletrolytes, and waste
**Indication:** when medications, diet, and fluid restrictions are no longer effective leading to uremic symptoms and fluid and electrolyte imbalances
176
What is used for accessing the body for short-term and long-term dialysis? How long does long-term access take to mature?
**1) Short-term:** HD catheter
**2) Long-term:** Arterial-venous fistula
- Takes up to 4 months to mature, 50% do not make it to maturity
177
Why are some medications given after hemodialysis?
They may dialyze off if given before and the patient loses out on whatever benefit it was supposed to give.
178
What education should you provide to someone with an AV fistula?
**1)** Do not carry heavy objects on the extremity
**2)** Do not sleep on or compress the extremity
**3)** Monitor for bleeding after dialysis (apply pressure)
**4)** Assess function and perfusion Q4H -> Bruit, thrills, distal pulse, capillary refill
**5)** No blood pressure taken on affected arm
**6)** No blood draws or IVs on affected arm
179
What is the main complication for peritoneal dialysis? How can we prevent this and what should you do if the effulent is cloudy and opaque?
**Complicaiton:** peritonitis
**Prevention:** Sterile insertion and technique when assessing catheter
**Clody and opaque effluent:** obtain a culture for labs
180
What is normal urine output per day?
0.5mL/kg/hr
or
1-3L/day
181
What amount of urine output would be concerning?
< 30mL/hr
or
< 500mL/day
182
What is acute kidney injury?
A rapid reduction in kidney function causing an inability to maintain proper fluid and electrolyte balance and acid-base balance
183
What are causes and risk factors for acute kidney injury?
**1)** Decreased perfuion to kidneys
- Dehydration
- Embolus or thrombus at renal arteries
- Sepsis or shock
- Myocardial infarction
**2)** Damage to kidney tissue
- Nephrotoxic medications (aspirin, NSAIDs like ibuprofen and naproxen)
- CT contrast
- Antibiotics (vancomycin, gentamicin)
- Diabetes
- Hypertension
**3)** Obstruction of urinary output
- Kidney stones
- Pyelonephritis
- Prostate cancer
184
What aspects of urine should you look at during suspected or confirmed AKI?
**1)** Color
**2)** Clarity
**3)** Amount
**4)** Odor
**5)** Frequency
< 30mL/hr for 2 hours or < 0.5mL/kg/hr = report
185
What should the nurse examine to determine if decreased perfusion is happening in acute kidney injury?
**1)** Low blood pressure, MAP < 65
**2)** High HR
**3)** Weak peripheral pulses
**4)** Decreased cognition
186
What lab findings would you expect in acute kidney injury?
**1)** Increased creatinine
**2)** Increased BUN
**3)** High serum osmolality and urine specific gravity
**4)** High K+ (metabolic acidosis - low bicarb)
**5)** Low GFR
**6)** High Phosphate
**7)** Low calcium
187
What diagnostics/imaging can you use during acute kidney injury?
**1)** CT
**2)** Ultrasound
**3)** Kidney biopsy during severe issues
188
How can acute kidney injury be prevented?
**1)** Drink 2-3L of fluid/day
**2)** Maintain a normal blood pressure
**3)** Reduce nephrotoxic medications
**4)** Monitor kidney function and increase fluids during contrast administration (**STOP** medformin 24 hours before contrast)
**5)** Redose medications as needed to prevent kidney injury
189
Why would temporary dialysis be used in acute kidney injury?
**1)** To treat symptomatic uremia (decrease in cognition)
**2)** High K+ levels, >6.5
**3)** Severe metabolic acidosis < 7.1 pH
**4)** Fluid overload
190
What is chronic kidney disease?
Progressive, irreversible, damage to the kidneys altering elimnation that has lasted longer than 3 months
191
What are the 5 stages with GFR of chronic kidney disease?
**1+2)** Often asymptomatic, risk factor reduction; GFR >90
**3)** Some symptoms, strategies to slow progression like ACE inhibitors; GFR 60-89
**4)** Manage complication, dialysis preparation; GFR 30-59
**5)** ESKD - dialysis or kidney transplant necessary; GFR < 30
192
What complications for each category would you expect to see in someone with chronic kidney disease?
1) Kidney
2) Metabolic
3) Cardiac
4) Hematologic
5) Immunity
6) GI
7) Cognitive
**1) Kidney:** fluid overload (crackles, edema, bounding pulse)
**2) Metabolic:** Hperkalemia (K+ high); metabolic acidosis (decreased acid secretion), hyperphosphatemia (high phosphate), hypocalcemia (low Ca2+)
**3) Cardiac:** hypertension, hyperlipidemia, heart failure, pericarditis
**4) Hematologic:** anemia (bleeding or bruising risk)
**5) Immunity:** infection risk
**6) GI:** N/V, anorexia
**7) Cognitive:** changing cognition with advanced disease
193
What is uremia and what are the signs and symptoms?
**Uremia:** azotemia, or the build up of nitrogenous waste in the blood, that causes symptoms
**S/S:**
**1)** Metallic taste in the mouth
**2)** Anorexia
**3)** Nausea
**4)** Vomiting
**5)** Muscle cramps
194
What are risk factors for chronic kidney injury?
**1)** Acute kidney injury
**2)** Hypertension
**3)** Diabetes
195
What signs and symptoms may be present in chronic kidney injury?
**1) Neuologic:** *lethargy and fatigue*, seizures, coma, upper extremity weakness
**2) Cardiovascular:** hypertension, fluid overload
**3) Respiratory:** metabolic acidosis causing tachypnea and Kussmal respirations to compsenate
**4) Hematologic:** anemia (bruising, bleeding), decreased WBC
**5) GI:** anorexia, nausea, vomiting, metallic taste, foul breath
**6) GU:** late stage oliguria and anuria
**7) Skin:** pruritis, dry skin, yellow/pallor or darkening
**8) Musculoskeletal:** weakness, bone pain, fracture
**9) Psychosocial:** depression, fatigue, sexual dysfunction
196
What labs or findings are present in chronic kidney injury?
**1) Urinalysis:** early protein, glucose, RBCs, WBCs, and low urine specific gravity
**2)** Early hyponatremia
**3)** Late hypernatremia (Worsens hypertension and fluid retention); hyperkalemia = dysrhythmias;
**4)** Reduced acid secretion = metabolic acidosis
**5)** hyperphosphatemia
**6)** Hypocalcemia
**7)** High BUN and Creatinine
**8)** Low GFR
197
How should you treat fluid and electrolyte imbalances in chronic kidney disease?
**1)** Dieurtics
**2)** Hemodialysis 3/week 3-4 hours or peritoneal dialysis in ESRD
**3)** Fluid status assessment = daily weights, I/O's, fluid overload S/S
**4)** Fluid restriction
**5)** Monitor electrolytes
**6) Medications:** phosphate binders, multivitamins
198
How do you improve cardiac function in chronic kidney disease?
**1)** Control hypertension by using diuretics (thiaizde), Ca2+ channel blockers, ACEIs, beta blockers
**2)** Monitor HF S/S
199
How do you improve nutrition in chronic kidney disease?
**1)** Consult a registered dietician
**2)** Restrict protein early on d/t difficulty metabolising and excreting it (more is allowed for hemodialysis patients)
**3)** Restrict sodium, potassium, and phosphorus
**4)** Fluid restrictions
**5)** Multivitamins, phosphate binders
**6)** Give Ca2+ with vitamin D and iron
200
Phosphate binders: what medication, what does it do, education, side effects
**Medication:** calcium acetate
**Action:** prevents absorption of dietary phosporus
**Education:**
- Take with meals
- Do not take within 2 hours of other medications
- Take after dialysis
- Monitor phosphorus and calcium levels
**Side effects: constipation**, weakness, pulse irregularity
201
Parathyroid Hormone Modulator: What medication, what does it do, side effects
**Medication:** Cinacalcet
**Action:** Reduces parathyroid hormone to maintain blood levels of Ca2+ and phosphorus
**Side effects:** diarrhea, muscle pain
202
Erythropoetin Stimulating Agents: what medication, what does it do, monitoring, side effects
**Medication:** erythropoetin alfa
**Action:** Prevents or corrects anemia
**Monitor:** high hemoglobin (too high is > 10-11) because it increased blood viscosity
**Side effects:** chest pain, high blood pressure, weight gain, swelling, hives
