Final Exam: New material Flashcards
1
Q
What is Grey-Turner’s sign
A
Purplish discoloration on the flanks or around the 11th/12th ribs
- indicative of renal injury
2
Q
which lab values are evaluated to check kidney function
A
- BUN (not conclusive)
- creatinine (reflects GFR)
- GFR (kidney function)
- osmolality (hydration)
- anion gap (acid/base balance in blood)
- hemoglobin/hematocrit (hydration status)
- albumin (high = dehydration)
- electrolytes (especially potassium, calcium, phosphorus)
3
Q
What are the components of a urinalysis
A
- pH
- specific gravity/osmolarity
- glucose
- protein
- electrolytes
- sediment
- blood
4
Q
What is dark brown (coca-cola) colored urine indicative of
A
Rhabdomyolysis
color is due to the myoglobin present in the urine
5
Q
What does it mean if there is protein in the urine
A
Measure of nephron injury/repair
The type of protein depends on the type of kidney disease (low molecular weight protein vs. albumin)
6
Q
What is GFR
A
Glomerular filtration rate
best measure of kidney function
> 60 = loss of 50% (or more) of normal kidney function
7
Q
How do we diagnose rhabdomyolysis
A
Blood test will show
- high potassium
- high phosphate
- low calcium
- high uric acid
- high creatinine kinase
8
Q
What are some causes of rhabdomyolysis
A
Direct muscle tissue damage
metabolic causes
drugs and toxins (statins, antifreeze, SSRIs)
9
Q
What is rhabdomyolysis
A
Breakdown of muscle tissue usually caused by trauma
10
Q
What is creatine kinase and what does it tell us
A
A protein found in skeletal muscle
- normal range is > 200
- CK > 1000 = rhabdomyolysis
- CK > 5000 = complications (acute renal failure, DIC, and hyperkalemia)
11
Q
What is DIC
A
Disseminated intravascular coagulation
Causes abnormal clotting in the vessels
12
Q
What is the treatment for rhabdomyolysis
A
- remove cause
- hyper hydration (4-6 L of fluid in 24 hours)
- alkalinize urine
- check CK levels every 4-6 hours
13
Q
What is creatinine clearance test
A
24 hour urine test
- discard first void
- collect every void in a container for 24 hours
- check urine for creatinine
14
Q
What symptoms do we see in a patient with a low GFR
A
- edema
- decreased output
- increased BP
15
Q
What is oliguria
A
reduced urine output
< 400 mL in 24 hours
16
Q
How much is normal urine output
A
0.5 mL/kg/hour
17
Q
How is acute kidney injury diagnosed
A
Rise in baseline Cr of at least 0.3 mg/dL in 48 hours, OR 50% higher than baseline in 1 week, OR reduction in urine output > 0.3 mL/kg/hr for 6 hours
Also with a rapid increase of BUN and decrease of GFR
18
Q
What are the three stages of renal injury
A
- pre-renal injury
- intra-renal injury
- post-renal injury
19
Q
What is pre-renal injury
A
Due to an issue before the kidney
Decrease in renal blood flow:
- depletion of vascular volume
- impaired perfusion due to HF
- distributive shock
- vasoconstriction of renal vessels (caused by drugs or contrast)
- reversible with treatment
20
Q
What lab values will we see with pre-renal injury
A
- Sharp decrease in GFR
- pre-renal azotemia
21
Q
What are some things that cause pre-renal injury
A
- Heart failure (decreased CO)
- massive bleeding
- dehydration
- burns
- drugs (vasoconstrictors)
- contrast dye
22
Q
What is pre-renal azotemia
A
- BUN/Cr ratio > 20
- hyaline casts in urine sediment
- urine specific gravity > 1. 018
- urine osmolality > 500 mOsm/kg
- irritants on skin cause itching
23
Q
What is intra-renal injury
A
Damage to structure within the kidney (glomerular, tubular, or interstitial)
- most commonly tubular (nephron)
- potentially reversible
24
Q
What are some causes of intra-renal injury
A
Acute tubular necrosis due to:
- ischemia (lack of blood flow)
- nephrotoxic drugs
- tubular obstruction (myoglobin, Hgb, uric acid, myeloma)
- massive infections
25
What are some nephrotoxic drugs
- chemotherapy agents
- antibiotics
- NSAIDs
- IV contrast dye
26
What is acute tubular necrosis
Destruction of tubular epithelium with acute suppression of renal function
27
What are the four phases of acute tubular necrosis
- onset (event to injury)
- oliguric (1-2 weeks)
- diuretic (1-3 weeks)
- recovery (up to a year if you get here)
28
what is the onset phase of ATN
Onset of precipitating event until injury to tubule occurs
(taking nephrotoxic drug until damage to tubule occurs)
29
What are the signs and symptoms of the oliguric phase of ATN
Increased BUN/creatinine
- neuro changes: fatigue, confusion
- itching (azotemia)
Hyperkalemia
- EKG changes: tall, peaked T waves, wide QRS, prolonged PR interval
Increased fluid in body
- Edema (risk of pulmonary/cardiac issues)
- hypertension
Metabolic acidosis
- confusion
- Kussmaul breathing
Mild Hyponatremia
- elevated phosphorus
- decreased calcium
- concentrated urine: specific gravity > 1.020
30
What are the signs and symptoms of the diuretic phase of ATN
- voiding 3-6 L of urine/day
- GFR improving
- can filter blood but cannot concentrate urine
31
What are the signs and symptoms of the recovery phase of ATN
- urine output 1-2 L/day
- GFR returns to normal
- BUN/Cr return to normal
- electrolytes return to normal
(some patients never make it to recovery)
32
What is pre-renal azotemia
- BUN/Cr ratio > 20
- hyaline casts in urine sediment
- urine specific gravity > 1. 018
- urine osmolality > 500 mOsm/kg
- irritants on skin cause itching
32
What is intrarenal renal failure
Renal failure in the tubules of the nephron due to ischemia, toxins from drugs, or toxins from massive infection
Usually caused by drugs: chemo, antibiotics, NSAIDs, or IV contrast dye
33
What is post renal failure
obstruction of urine outflow from the kidneys, to the bladder, and out of the body
- renal calculi in the ureter
- neurogenic bladder or tumors in the bladder
- benign prostatic hyperplasia blocking urine flow in the urethra
34
What is the most common clinical manifestation of acute renal failure
oliguria (abnormally small amounts of urine)
35
What are the major electrolyte imbalances that we see with acute renal failure
Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Hyponatremia
36
How do we assess for hyperkalemia
- Peaked T waves
- widened QRS interval
- can lead to V tach or V fib
37
How do we treat hyperkalemia
Immediately administer calcium, insulin, glucose, and albuterol along with kayexalate or lokalma
- calcium: stabilizes resting membrane potential to prevent arrhythmias
- insulin: forces potassium into the cells to lower serum K levels
- glucose: to prevent hypoglycemia from insulin
- albuterol: shifts potassium into intracellular space
- kayexalate: binds K and brings it out in stool
- lokalma: like kayexalate but doesn't cause diarrhea
38
How do we treat hypocalcemia
calcium replacement and vitamin D
39
How do we treat hyperphosphatemia
phosphorus binding drugs:
- aluminum
- calcium salts
- Renagel
- Fosrenol
40
What are the major complications of acute renal failure
Hyperkalemia
Metabolic acidosis
Anemia
Prolonged bleeding time
Infections
cardiac complications
Malnutrition
41
What is chronic kidney disease
The continual and irreversible reduction in nephron number
42
What are some things that can cause CKD
Diabetes
Hypertension
Glomerulonephritis
Polycystic disease
43
What is hemodialysis
patient with Kidney disease do this three times a week in order to filter toxins out of their blood since their kidneys cant.
a Quinton catheter is inserted into a vein (Usually subclavian but can also use femoral) or a fistula or AV graft (long term use)
44
What is CRRT
Continuous renal replacement therapy
- Hemodialysis but continuous
45
What is peritoneal dialysis
For patients with CKD; long term dialysis
a catheter is placed in the peritoneum and then is routinely drained and filled with new fluid
Catheter care is very important! (peritonitis)
46
What are some major complications of dialysis
- Hyperkalemia
- Pericarditis
- Pericardial effusion
- Pericardial Tamponade
- Hypertension
- Anemia
- Bone disease and metastatic calcifications
- ACCESS
- peritonitis (PD)
47
Wat is uremic frost
Yellow crystals on the skin from urea in sweat
usually occurs in BUN > 200
48
What is normal A1C in lab values
4-7%
49
What are the actions of insulin
- promote cellular glucose uptake
- promote glucose storage into glycogen
- prevents fat and glycogen breakdown
- inhibits gluconeogenesis
- increases protein synthesis
50
What are the characteristics of type I diabetes
- Always insulin dependent
- caused by pancreatic beta-cell destruction
- fatty acids are converted to ketones in liver
51
WHat are the characteristics of type II diabetes
- caused by genetics, drugs, or toxins
- peripheral insulin resistance
- increased glucose production in liver
- upper body obesity
52
What are the criteria for metabolic syndrome
- abdominal obesity
- triglycerides > 150
- HDL < 50
- BP > 130/85
- fasting glucose > 110
53
What are some symptoms of diabetes
- polydipsia
- polyuria
- polyphagia
- thirst
- hunger
- weight loss (Type I)
- blurred vision, fatigue, paresthesia, and skin infection (Type II)
54
What are some medical management methods for diabetes
- diet
- exercise
- insulin (injections, inhalations, and pumps)
- oral medications
55
What are some oral medications for diabetes
Sulfonylureas: beta cell stimulant
Biguanides: prevents glucose production (metformin)
Alpha-glucosidase inhibitors: stop carb absorption in small intestine
Thiazolidinediones: insulin sensitizers
56
What are some common insulin medications
aspart (Novolog) - ultra-short acting
glulisine (Apidra) - ultra short acting
lispro (Humalog) - ultra short acting
Human regular (Humulin R or Novolin R) - short acting
Human NPH (Humulin N or Novolin N) - intermediate
Detemir (Levemir) - long acting
glargine (Lantus) - long acting
57
What is diabetic neuropathy
somatic neuropathy- loss of sensation of pain, vibration, and temperature and increased sensation to light touch (feels like burning)
Autonomic neuropathy - loss of function in autonomic processes such as vasomotor, cardiac, GI (gastroparesis), neurogenic bladder, and sexual dysfunction
58
What are the signs and symptoms of hypoglycemia
- hunger
- anxiety
- tachycardia
- sweating
- cool, clammy skin
- altered mental status
- seizures
- coma
59
What are some treatments for hypoglycemia
1/2 cup of juice followed by starch and protein
- cheese/crackers, milk/crackers, ham sandwich
1 amp D50 IV push (100 calories)
- half life only 30 minutes
60
What is diabetic ketoacidosis
Seen in type 1
caused by
- physical stressors (surgery, infection, trauma)
- low insulin (diet/exercise changes, faulty insulin pump)
- pregnancy
- growth spurts
- emotional stress
- drugs (steroids, epinephrine/norepinephrine)
61
How is DKA diagnosed
- Glucose > 300
- HCO3 < 15
- pH < 7.3 (metabolic acidosis with respiratory - alkalosis to compensate)
- rising anion gap
- urine ketones
- sudden onset
62
What are the signs and symptoms of DKA
- polyuria
- polydipsia
- polyphagia
- severe fatigue
- fruity breath
- kussmaul breathing
- N/V
- hypovolemia (hypotension, tachycardia)
63
What are the treatment methods for DKA
- correct insulin problem (fix pump)
- give fluids
- correct acidosis but DO NOT give HCO3 unless in cardiac arrest
- do not treat hyperkalemia because insulin will drop serum K
- careful, low doses of insulin IV (extreme acidosis can cause insulin resistance)
- add glucose to insulin IV when sugar < 200-250 to avoid hypoglycemia
- monitor anion gap
64
What is hyperglycemic hyperosmolar state
Seen in type II diabetes
caused by
- insufficient insulin
- infection
65
How do we diagnose HHS
- Hyperglycemia > 600
- hyperosmolarity > 320 mmols/kg
- dehydration
- absence of acidosis
- ketones absent or mild
- gradual onset
66
what are the signs and symptoms of HHS
- glucose > 600
- polyuria
- polydipsia
- dehydration (dry mucous membranes, tented skin turgor)
- fever
- fatigue
- mental status changes (confusion, seizure)
- coma
67
What is the treatment method for HHS
- Meticulous rehydration
- Replacement of K
- monitor fluid status and neuro status
- treat underlying cause
68
69
What is diabetes insipidus
Insufficiency of antidiuretic hormone (ADH)
- ADH makes tubules reuptake water
- large amounts of water are lost
- leads to dehydration, hypernatremia, and hypovolemia/hypotension
70
What are the three types of diabetes insipidus
Central - birth defect/unknown cause
nephrogenic - no response to ADH from kidney
psychogenic - rare; compulsive water drinking
71
How do we diagnose diabetes insipidus
- Urine output > 300 mL/hr
- Low urine specific gravity
- High serum osmolality
- Hypernatremia
- Check ADH levels (either there isn't enough or the kidneys aren't responding to it)
72
How do we treat diabetes insipidus
- Treat cause
- Hourly urine output (match with IV intake)
- Vasopressin (for central DI)
- Desmopressin (DDAVP) for less severe cases
- Thiazide diuretics (nephrogenic DI)
73
Why give a diuretic for diabetes insipidus
Thiazide diuretics help shift fluid back where it needs to be rather than having the patient pee it out
74
What is syndrome of inappropriate antidiuretic hormone (SIADH)
Opposite of diabetes insipidus
- too much ADH
- kidney reabsorb too much water
- hyponatremia
75
What causes SIADH
- Head trauma (damage to hypothalamus)
- small cell carcinoma
- stress
- medications (thiazides, chemo)
76
How do we diagnose SIADH
Sodium < 120
serum osmolality < 250
concentrated urine (high specific gravity)
low urine output
77
What are the signs and symptoms of SIADH
- lethargy
- confusion
- anorexia
- seizure
- coma
- death
78
How do we treat SIADH
- Fluid restriction < 500 mL
- hypertonic NaCl infusion (3-5%)
- stop drugs that can cause SIADH
- monitor hydration status
- seizure precautions
79
Compare SIADH to DI:
- urine output
- ADH levels
- sodium levels
- hydration status
- movement of fluid
80
What are the signs and symptoms of high cortisol levels
- extreme fatigue
- weight loss
- decreased appetite
- dehydration
- darkening of skin
- low blood pressure
- fainting
- salt craving
- low blood sugar
81
What is Cushing's syndrome
Hypersecretion of cortisol
caused by :
- pituitary creates too much adrenocorticotropic hormone (ACTH)
- glucocorticoid therapy
82
what are the signs and symptoms of Cushing's Syndrome
- fragile skin
- truncal obesity
- round face
- sexual dysfunction (amenorrhea/ED)
- bruising
- hypertension
- purple striae on abdomen and extremities
- hyperglycemia
- excessive body hair in women
- hypokalemia
- buffalo hump
- depression
83
What is Addison's disease
Hyposecretion of cortisol and aldosterone
caused by:
- autoimmune disease
- tuberculosis/infections
- cancer
- trauma
84
What are the signs and symptoms of Addison's disease
- hypoglycemia
- hyponatremia
- salt cravings
- fatigue
- muscle weakness
- hyperkalemia
- hypercalcemia
- irregular menstruation/ED
- hypotension
- darkening of skin
- diarrhea
- nausea
- depression
85
What are the 5 S's of Addison crisis
S - Sudden pain (in stomach, back, and legs)
S - Syncope
S - Shock
S - Super low BP
S - Severe vomiting, diarrhea, headache
86
Signs and symptoms of hyperthyroidism
- weight loss
- heat intolerance
- tachycardia
- hypertension
- diarrhea
- smooth skin
- soft hair
- dysrhythmias: a-fib
- personality changes: irritability, insomnia
- irregular menstruation
87
What is thyroid storm
life threatening condition that's caused by uncontrolled hyperthyroidism. Same symptoms except worse plus fever
TSH very low
T3 and T4 very high
hypocalcemia
88
How do we treat hyperthyroidism
radioactive iodine
thyroidectomy
89
What do we need to teach patients who are taking radioactive iodine
avoid iodine rich food: sea food, dairy, eggs
no aspirin: increases thyroid hormone
signs and symptoms of hypothyroidism
90
What is Grave's Disease
autoimmune hyperthyroidism
S/S: protruding eyes, goiter, thin body, jittery
91
What is myxedema coma
severe hypothyroidism with hypothermia and coma; usually believed that pt is just depressed
- confused
- hypothermic
- waxy buildup on skin
92
What is Pheochromocytoma
Tumor of the adrenal medulla
Causes: 5 H's
H - hypertension
H - headache
H - hyperglycemia
H - hyper metabolism
H - hyperhidrosis (excessive sweating)
93
What are the 4 stages of shock
initial: S/S hard to pinpoint
compensatory: body tries to reverse condition
progressive: multiorgan symptoms (compensation failed) MAP < 60
refractory: unmanageable; organs begin to fail
94
What is the SIRS criteria
Systemic inflammatory response system: assessment for shock (usually sepstic)
Temp > 38 or < 36
HR > 90
RR > 20
CO2 < 32
95
What do we do for MODS (multiorgan dysfunction syndrome)
- fluid resuscitation
- hemodynamic support
- treat infection
- prevent further infection
- maintain tissue oxygenation
- nutritional support
- comfort
- support individual organ function
96
What do we do for septic shock
- vasopressors
- fluids
- blood cultures
- antibiotics
- emotional support
- monitor for complications
97
What are the signs and symptoms of hypovolemic shock
low bp
tachycardia
low urine output
cool clammy skin
mental status changes
tachypnea
swaeting
