Exam 3 Overview Flashcards
How much protein do we normally want with CKD (on average)? PREDIALYSIS
0.55-0.60 g/kg/day
→ ~40g of protein/day
Protein needs _________ (increase/decrease) with dialysis.
Increase
→ 1-1.2 g/kg/day
How can reduced protein help with renal issues?
It can preserve kidney function, but we need to ensure adequate amt.
What is uremia?
Buildup of protein waste
What is one way to lower uremia levels?
LOWER PROTEIN! ◡̈
Normal GFR is >____?
90
Albumin normal range?
3.4 to 5.4 g/dL
Decreased serum prealbumin = ____ _________
low protein
A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a
reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most
concern?
* a. Albumin level of 2.5 g/dL
* b. Phosphorus level of 5 mg/dL
* c. Sodium level of 135 mmol/L
* d. Potassium level of 5.5 mmol/L
a. Albumin level of 2.5 g/dL (too low; not enough for metabolic needs.)
Name 4 meds used to prevent renal damage
Diuretics, ACE inhibitors, BBs, CCBs
When are diuretics typically used in CKD?
Mild to severe CKD
→ not typically used AFTER dialysis is stated
What are some things we might want to monitor with diuretics?
Monitor for ototoxicity (furosemide) + urinary output/electrolytes
How do CCBs help prevent renal damage?
Improve GFR & blood flow to kidneys
How do BBs inhibitors help prevent renal damage?
Help increase cardiac output/ avoid heart failure (reduced perfusion of kidneys → accelerated kidney disease)
A client has a long history of hypertension. Which category of medications would the
nurse expect to be ordered to avoid chronic kidney disease (CKD)?
* a. Antibiotic
* b. Histamine blocker
* c. Bronchodilator
* d. Angiotensin-converting enzyme (ACE) inhibitor
d. Angiotensin-converting enzyme (ACE) inhibitor → anti-HTN
What outcomes are best way to assess for desired outcomes r/t Lasix therapy?
→ Decreased urinary retention/increased urinary output (or, elimination) of fluid – no bladder distension
→ No crackles in lungs (indicative of no fluid volume overload)
→ Reduced SHOB, Lower BP
→ Weight Loss (r/t decrease in fluid retention!)
Stage 1 CKD GFR and description of stage:
NORMAL GFR
→ Increased risk for kidney damage – provide education!!
Stage 2 CKD GFR and description of stage:
GFR (60-89)
→ Mild disease/decrease in kidney function
Stage 3 CKD GFR and description of stage:
GFR (30-59)
→ Moderate disease
→ Azotemia present
→ Restriction of fluids (typically begin Lasix)
Stage 4 CKD GFR and description of stage:
GFR (15-29)
→ Severe disease/cannot maintain Acid-Base and Fluid-Electrolyte balance
→ Dialysis may be needed/
Stage 5 CKD GFR and description of stage:
GFR < 15
→ Dialysis or death/Transplant?
What respiratory pattern can indicate worsening renal failure?
Kussmaul respirations
Renal issues = hyper/hypokalemia?
Hyperkalemia
Lots of the kalemias
A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2
mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?
a. Place the client on a cardiac monitor immediately.
b. Teach the client to limit high-potassium foods.
c. Continue to monitor the clients intake and output.
d. Ask to have the laboratory redraw the blood specimen.
a. Place the client on a cardiac monitor immediately.
A nurse is assessing a client who has an electrolyte imbalance related to renal failure.
For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
- a. Electrocardiogram changes
- b. Slow, shallow respirations
- c. Orthostatic hypotension
- d. Paralytic ileus
- e. Skeletal muscle weakness
a. Electrocardiogram changes
d. Paralytic ileus
e. Skeletal muscle weakness
- Electrolyte imbalances associated with acute renal failure include hyperkalemia and
hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus
caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia.
The other choices are potential complications of hypokalemia.
Reduced perfusion (i.e., decreased blood flow to kidneys) = _________
PRERENAL
Name some types of prerenal failure
→ Shock/Hemorrhage (hypovolemia)
→ Severe Burns (r/t fluid volume loss?)
→ Hypotension/Cardiac Damage – reduced or impaired cardiac output (ex. MI)
→ Anything that blocks blood flow to kidneys (Atherosclerosis)
The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI).
Which condition would the nurse expect to find in the clients recent history?
- a. Pyelonephritis
- b. Myocardial infarction
- c. Bladder cancer
- d. Kidney stones
b. Myocardial infarction
→ Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage.
Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.
What kinds of respiratory issues can you see with renal failure?
→ Kussmaul’s Breathing (per Iggy – worsening renal failure)
→ Others include: SHOB, crackles, dyspnea, increased RR
What it is epogen and why do patients with CRF need it?
Epogen is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and not on dialysis to decrease the need for red blood cell (RBC) transfusion
What is the max dosage of epogen?
Individ. dose no higher than 10-11 g/dL.
Why would someone have anemia with renal failure? And how does epogen help?
Epogen (or, epoetin alfa) helps the body create more red blood cells. – damaged kidneys are
unable to effectively make erythropoietin
Talk renal failure nutrition to me.
Protein:
Potassium:
Phosphorus:
Sodium?
→ Protein: Reduced (0.55-0.6g/kg/day) until dialysis when we increase it (1-1.2g/kg/day)
→ Potassium restricted: 60-70mEq/day
→ Phosphorus restriction. Phosphate binder w/ meals
→ Na restriction before dialysis (1-3 g/day), then increase after dialysis (2-4g/day)
→ Supplements
What are some things we would do re: prevention of worsening renal failure (education/ lifestyle changes)?
Meds (CCB, ACE, BBs, diuretics), daily weights, daily BP, fluid restrictions, no nephrotoxic meds (renal dosing if you gotta take it), dialysis
What is the calculation for fluid restriction amount for renal failure?
UOP (day prior) + 500mL – general estimate
Post-renal failure is a problem of ___________.
Obstruction (i.e., urine cannot get out!)
Name some causes of post-renal failure.
→ Bladder Cancer
→ Kidney Stones
→ Prostate cancer or benign prostatic hyperplasia (BPH)
→ Cervical cancer
Where can AV fistulas be created?
Radial, brachial, or cephalic
AV fistulas increase venous blood flow to:
250-400mL/min
Re: AV fistula: Vessel walls need to _________ to accommodate accessing. How long does this take?
Thicken; 6 months
How do you do right by a fistula (assessment, what to do and what not to do)?
→ No blood pressures or venipunctures on fistula extremity
→ Hang a sign over bed
→ Feel for a thrill and listen for a bruit, every four hours
→ Assess distal pulses
→ Assess for signs of infection
→ Avoid placing pressure on fistula extremity
What is the most common fistula complication?
Thrombosis
→ tPA can be used to dissolve clot
Name 3 other common fistula complications and how we would resolve them?
Strictures
→ Balloon angioplasty
Infection
→ Use sterile procedure when accessing(!!)
Ischemia (reduced arterial blood flow below fistula; “steal syndrome”)
→ New fistula
Heart failure and acute renal failure: What is the relationship and what are goals when a person with HF develops ARF related to the HF?
Fluid volume overload/HTN – reduced perfusion to kidneys; give BB to help increase CO
What is CRRT and when is it used?
Continuous Renal Replacement Therapy
→ In an emergency only
→ Dialysis for the unstable patient
→ Utilized for Acute Kidney Injury or when patient with CRF is hemodynamically unstable
Is CRRT fast or slow?
Slllloooooowwwwwww
CRRT avoids large __________ like you see in hemodialysis but provides the same result
Avoids large volume shifts
Where is CRRT usually performed? And how long does it run?
ICU, usually a 1:1 ration. Runs 24 hours a day.
CRRT is hemofiltration that works by using a a ________ (unlike HD’s diffusion process)
Filter with fine pores
Priority assessment finding during CRRT management?
BLOOD PRESSURE!!
→ Keep SBP >90mmHg or pt. could code!!
What are some kidney transplant critera?
Must be in End Stage Renal Disease and free from other medical issues that increase complications
→ Advanced Cardiac Disease
→ Cancer within 3-5 years
→ Untreated GI issues
→ Addiction
→ Chronic Infection
→ Pulmonary disease
→ Advanced age
Basically ya gotta be young and perfect.
What happens during the pre-surgical stage of a kidney transplant?
→ Tissue matching
→ Live donor trading
→ Education
What happens to the old kidneys in a trnasplant?
They stay!
Where does the new kid(ney) go?
Anterior iliac fossa
What is a big sign of rejection after a transplant?
Decrease in UOP
What is another big complication post-transplant and when can it happen? What is the main sign of this?
Thrombosis
→ w/in 2-3 days after surgery
→ Decrease in UOP
Nursing priorities post-transplant?
→ I’s & O’s
→ Electrolytes
→ Diuretics
→ Urine catheter removal
→ Education regarding medication adherence
* Corticosteroids
* Inhibitors of t-cell proliferation
* Monoclonal inhibitors
* mTOR inhibitors
→ Monitor for S/S of infection(!!)
* Low-grade fever
* Confusion
* Pain
Symptoms of all thrombocytopenia are first seen where?
In the skin and mucous membranes
In assessing for thrombocytopenia, what might you see?
- Excessive bleeding in the tissues
→ Bruises
→ Petechiae
→ Purpura (reddish purple fine petechial rash
→ Mucous membrane bleeding
In addition to excessive bleeding, a complication we should watch for with thrombocytopenia is (specific):
Microclots
How might microclots cause damage?
Block capillaries of organs and tissue, leading to ischemia
→ Kidneys
→ Cardiac
→ Brain
With HIT, there are also potential complications of (2):
→ Venous Thromboembolism (VTE)
→ Pulmonary Embolism
When do we do a platelet transfusion (number)?
<10,000/mm3
Platelets <_______/mm3 high risk for bleeding
Platelets <______/mm3 at risk for spontaneous bleed
50,000; 20,000
What is pancytopenia?
Deficiency in all three of the good-goods: RBC’s, platelets, and WBC’s.
What are the normal ranges for RBC’s, WBC’s, and platelets?
→ RBC’s 4-6 million/uL
→ WBC’s 4,500-11,000/uL
→ Platelets 150,000-450,000 /uL
With burn patients, what is a main source of infection we worry about?
Auto-contamination
WTF is auto-contamination? Like, when you have a dirty car?
Overgrowth of normal flora (bacteria from SELF!!) – can lead to sepsis in immunocompromised
Where are the most common sites of auto-contamination infection with burn patients?
→ Skin – breakdown/wounds?
→ Respiratory – cough?
→ GI tract
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by auto-contamination?
A. Use a disposable blood pressure cuff to avoid sharing with other clients.
B. Change gloves between wound care on different parts of the clients body.
C. Use the closed method of burn wound management for all wound care.
D. Advocate for proper and consistent handwashing by all members of the staff.
B. Change gloves between wound care on different parts of the client’s body.
→ Auto-contamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client’s body can prevent auto-contamination.
What are the main assessments we would do to watch for infection with a burn patient?
→ CBC with Diff—WBC, Absolute neutrophils
→ Respiratory assessment
→ Assess urination and urine
→ VS with TEMPERATURE [fever (i.e., temp elevated 1 degree above baseline) = cause for concern; notify physician!!] – know this!!
If infection is suspected in a burn patient what would happen next?
- If infection SUSPECTED –> Pan Culture, X rays, IV antibiotics
Name some various Interventions to Implement if you have a patient with burns.
→ Specialized unit – NO roommates(!!)
→ HANDWASHING
→ Aseptic Technique
→ Pulmonary hygiene (cough, deep breathing, ambulation, IS)
→ Skincare (turn, barrier creams, etc.)
→ Ensure those who enter room are not sick, visitors or staff
What kind of precautions do we use with burn patients?
Neutropenic precautions
What might be the only symptom at a lymphoma diagnosis?
Lymph node swelling (large and painless)
What are “B symptoms” with lymphoma? And what do they generally mean?
→ Drenching night sweats
→ Losing weight w/o trying
→ High fever of 37.5 that does NOT go away
These symptoms mean poorer prognosis
Which is more common, Hodgkin’s or Non-Hodgkin’s Lymphoma?
Non-Hodgkin’s
Hodgkin’s or Non-Hodgkin’s Lymphoma: Presence of Reed-Sternberg cells.
Hodgkin’s
Hodgkin’s or Non-Hodgkin’s Lymphoma: Predictable spread from one group of lymph nodes to the next; often starts in single lymph node or single chain of nodes.
Hodgkin’s
Hodgkin’s or Non-Hodgkin’s Lymphoma: Over 60 subtypes.
Non-Hodgkin’s Lymphoma
Hodgkin’s or Non-Hodgkin’s Lymphoma: Possibly from a viral infection.
Hodgkin’s
→ Epstein Barr virus
→ HIV
→ Human T cell leukemia/lymphoma virus
Hodgkin’s or Non-Hodgkin’s Lymphoma: Generally the patient is < 40 years old.
Hodgkin’s
Hodgkin’s or Non-Hodgkin’s Lymphoma: Exact cause unknown.
BOTH!
What are some risk factors for Non-Hodgkin’s Lymphoma?
Immune system issues
→ Organ transplants, immunosuppressed
→ HIV
→ Chronic infections
→ Exposure to dust, pesticides, and insecticides
Side iffects of going through treatment for H/NHL?
→ Pancytopenia
Infection
Anemia
Bleeding
→ Skin issues
→ Nausea & vomiting
→ Constipation or diarrhea
→ Sterility
→ Secondary cancer
WTF is happening with Multiple Myeloma?
Plasma cells secrete antibodies
→ Cancer cells secrete EXCESS antibodies (gamma globulins)
→ Excess antibodies in the blood
→ Increased protein levels
→ “Clog” up blood vessels to kidney and other organs
What do we call a cancerous plasma cell?
Myeloma cell
What do myeloma cells do?
Produce EXCESS cytokines
→ Increase cancer cell growth and bone destruction
Excessive myeloma cells reduce production of what? What does this lead to?
Platelets, RBC’s, and WBC’s, leading to pancytopenia
Why is is especially important to monitor urinary output with burns?
Monitor fluid balance – dehydration = increased risk r/t burns(!!)
→ Helps to inform provider/nurse as to how
much IV fluids to give!
In large burns or when airway burn injury is suspected, patient should be ________ before airway swelling occurs.
Intubated
Why does airway edema sometimes happen 8-12 hours after fluid administration begins?
Because of dehydration
What are some things to consider re: airway with burn patients (5)?
→ Monitor respiratory status
→ Bronchoscopy
→ Suction
→ Ensure patient is moving chest adequately
→ Oxygen
An emergency room nurse assesses a client who was rescued from a home fire.
The client suddenly develops a loud, brassy cough. Which action should the nurse take first?
A. Apply oxygen and continuous pulse oximetry.
B. Provide small quantities of ice chips and sips of water.
C. Request a prescription for an antitussive medication.
D. Ask the respiratory therapist to provide humidified air.
A. Apply oxygen and continuous pulse oximetry.
→ Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.
What will we see 24-36 hours after a large burn (> 25% BSA)?
→ Microvascular injury causes increased vascular permeability
→ Fluid shifts/ 3rd spacing (Capillary Leak Syndrome) EDEMA
→ Hyperkalemia
→ Hypovolemia/tachycardia/reduced cardiac output
→ Loss of Protein
What will we see 48-72 hours after a large burn (> 25% BSA)?
→ Diuresis/capillary leaking ends
→ Hypokalemia
→ Protein loss
Severe burn injuries lead to ___________ development.
Acute kidney injury (AKI)
What is usually the first sign of AKI with burns?
Reduced urine output despite adequate fluid
administration
Things to do to help prevent burns?
→ Smoke Detectors
→ Adjust hot water heater
→ Turn pot handles away from reach
→ Safe use of Oxygen (no open flames)
How do we calculate the TBSA with burns?
→ Divide the body into areas that are multiples of 9%
→ Assess depth (based on characteristics)
A nurse uses the rule of nines to assess a client with burn injuries to the entire
back region and left arm. How should the nurse document the percentage of the clients body that sustained
burns?
A. 9%
B. 18%
C. 27%
D. 36%
C. 27%
→ According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body
How do we calculate fluid administration for a patient with burns?
Parkland Formula for Fluid Resuscitation
Tell me how to use the Parkland Formula for Fluid Resuscitation?
Over first 24 hours:
→ LR given 4ml/kg per %TBSA
→ Give ½ of this volume in first 8 hours, the other half over next 16 hours
An emergency room nurse cares for a client admitted with a 50% burn injury at
10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr
1500 mL/hr
→ The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during
the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.
4 x 90 kg = 360
360 x 50% = 18,000
Identify this burn classification:
→ Only epidermis is burned
→ Sunburn
→ Redness
→ Mild edema
→ Pain
→ Peeling of dead skin
→ 2-3 days after burn
→ Healing in 3-6 days
Superficial-Thickness Burns
Identify this burn classification:
→ Injury to upper third of dermis
→ Pink, moist and blanchable
→ Blister formation
→ Painful
→ Heal in 10-21 days
→ No scar but there is pigment change
Superficial Partial Thickness
Identify this burn classification:
→ Extend deeper into dermis layer
→ No blister formation
→ Red & Dry
→ White patches (deeper)
→ Less Pain
→ Heal in 2-6 weeks with scar formation
Deep Partial Thickness
Identify this burn classification:
→ Destruction of entire epidermis and dermis
→ No skin cells intact
→ Does not regrow
→ Wound contracture or skin grafts
→ Hard, dry eschar (dead tissue)
→ Must come off for healing to occur
→ Severe edema under eschar
→ Waxy white
→ Deep red
→ Yellow
→ Brown
→ Black
→ No sensation
Full-Thickness Burns
Identify this burn classification:
→ Around Chest
→ Blood flow and breathing may be compromised from tightening eschar
Circumferential Full-Thickness Burns
Identify this burn classification:
→ Include damaged bone, tendon, muscle
→ Flame, electrical or chemical fires
→ No sensation
→ Blackened & depressed
→ Grafting required
→ Amputation may be necessary
Deep Full-Thickness Burns
A nurse reviews the following data in the chart of a client with burn injuries:
Admission Notes
* 36-year-old female with bilateral leg burns
* NKDA
* Health history of asthma and seasonal allergies
Wound Assessment
* Bilateral leg burns present with a white and leather-like appearance.
* No blisters or bleeding present.
* Client rates pain 2/10 on a scale of 0- 10.
Based on the data provided, how should the nurse categorize this client’s injuries?
A. Partial-thickness deep
B. Partial-thickness superficial
C. Full thickness
D. Superficial
C. Full thickness
The characteristics of the client’s wounds meet the criteria for a full-thickness injury: color
that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic
outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.
What are DKA standard orders?
→ Rehydration
→ Insulin therapy – GO SLOW(!!)
→ Electrolyte repletion
→ Management of complications and evaluation of therapy
What is the norm for fluids with DKA (3)?
- 15-20mL/kg over the first hour * 100kg? 1500-2000 mL
- 4-14mL/kg/hr hypotonic fluids until serum glucose </=250
- Once CBG </=250, D51/2NS
Talk me through insulin administration with DKA.
→ IV Administration of Insulin drip
→ Initial bolus dose = 0.1 units/kg
→ Start infusion at 0.1 units/kg/hr
→ Follow algorithm to reduce the serum glucose by 50-75 mg/dL/hr
When do we utilize bicarb with DKA?
Only utilized for severe acidosis (pH </= 7.0)
How do we give bicarb with DKA?
Given slowly over several hours
→ As acidosis resolves, remember that the potassium will drop (as K+ goes from plasma back into the cell
Obvi we want to monitor for signs of hypokalemia as all of this is happening. What are we looking for?
→ Fatigue
→ Hypotension/weak pulse
→ Shallow respirations
→ Muscle weakness
When do we start ADDING potassium back in with DKA?
Once potassium is below high-normal range – typically added to fluids
