Module 3 Blueprint Flashcards
the kidneys are responsible for
filtering water and wastes from the blood stream
what are the functions of the kidney
maintaining body fluid volume, creating urine, regulating blood pressure, acid-base balance, produce erythropoietin, and convert vitamin D
what is renal agenesis
person born with only one kidney
what is kidney dysplasia
born with two kidneys but only one yes
What is the functional unit of the kidney
the nephron
What does the nephron do
forms urine by filtering waste products and water from the blood
what do juxtaglomerular and macula densa cells do
macula densa: detects changes in blood volume and pressure
juxtaglomerular: produce renin
what does renin regulate
blood flow, glomerular filtration rate, and blood pressure
when is renin produced by the juxtaglomerular cells
blood volume, blood pressure, or sodium levels are low
explain the RAAS system
renin –> angiotensinogen –> angiotensin 1 –> angiotensin 2 –> aldosterone
what does aldosterone do
increase kidney reabsorption of sodium and water, promotes excretion of potassium
explain blood supply through the nephron
afferent arteriole -> glomerulus (water and small particles filtered to make urine) –> proximal convulated tubule–> descending loop of henle –> ascending loop of henle –> distal convoluted tubule –> collecting duct
the remaining blood not filtered in the glomerulus leaves through the
efferent arteriole
the regulatory function of the kidney controls
fluid and electrolyte, acid and base balance
the hormonal functions of the kidney control
RBC formation, blood pressure, and vitamin D activation
the kidneys can manage regulatory functions through urine elimination. What are the processes involved in urine elimination
glomerular filtration, tubular reabsorption, tubular secretion
what particles are allowed to be filtered across the glomerular membrane to form glomerular filtrate?
water, electrolytes, other small particles (creatinine, urea nitrogen, glucose)
What particles are too large to be filtered through glomerular capillary walls and are not commonly found in urine
blood cells, albumin, other proteins
Normal glomerular filtration rate
125 mL/min
How many L/day do we excrete in urine and why?
1-3L/day to prevent dehydration, much of waste produced by glomerulus is reabsorbed
GFR is controlled by
blood pressure and blood flow (the kidneys regulate their own blood pressure to keep GFR constant)
How do the kidneys control their own blood pressure
dilating and constricting the afferent and efferent arteriole
“when the systolic blood pressure drops below 65-70 mmhg”
“self regulation processes do not maintain GFR”
What is the second process in urine formation
tubular reabsorption
What does tubular reabsorption prevent
dehydration
How does tubular reabsorption work
as filtrate passes through tubular parts of nephron, water and electrolytes are reabsorbed in the capillaries (99%)
What is the renal glucose threshold
tubular reabsorption can reabsorb glucose until it gets above 180, then it spills into urine and we have glycosuria
When aldosterone is present, it promotes what to happen to sodium
sodium reabsorption in the distal convoluted tubule (water then follows)
how does tubular reabsorption control acid-base balance
bicarbonate absorption (along with calcium and phosphate)
what should the nurse do in the presence of glucose or proteins in the blood
report to provider as this is an abnormal finding
What is the third process of urine formation
tubular secretion
What does tubular secretion do
allows substances to move from the blood to the urine
What substances are moved into the urine through tubular secretion and why
potassium and hydrogen ions to maintain fluid and electrolyte balance/acid-base balance
the RAAS system is activated by the kidneys to raise
blood sodium levels –> in turn raises blood volume levels and blood pressure
What do the prostaglandins of the kidneys do
regulate glomerular filtration by dilation and constricting vessels,
what does erythropoietin do
produced and released in response to decreased oxygen –> triggers RBC production in bone marrow
What disease process could occur if erythropoietin is decreased
anemia
The kidney converts vitamin D into its
active form
What is the function of activated vitamin D
increase absorption of calcium in GI tract
What two structures do the ureters connect
kidneys to the urinary bladder
What is continence
the ability to voluntarily control bladder emptying
during micturition, does the external sphincter relax or contract
relax
what is the urethra
tube that allows excretion of urine from the bladder
how long is the urethra in males
6-8 inches
how long is the urethra in females
1-1.5
a sudden onset of hypertension in patients older than 50 years can indicate
kidney disease
in men older than 50 years, altered urine patterns are typically caused by
prostate disease
Why are UTIs and cystitis more common in women
the shorter urethra
ingestion of how much fluid / day is recommended
2L
a high intake of protein can affect our kidneys how?
increase risk for stones
What is nocturia
frequent voiding at night
Types of UA?
early morning, 24 hour, random, c/s, clean catch
pain that radiates into the perineal area, groin, scrotu,, or labia is known as
renal colic
Why do we do early morning?
urine is more concentrated.
renal colic pain may be intermittent or continuous, and the patient can present with other symptoms such as
pallor/ash gray skin, diaphoresis, hypotension
What does a UA do?
identifies the color, clarity, concentration or dilution, specific gravity, acid/alkaline, and presence of drug metabolites, glucose, ketones and proteins.
What should not be present in the urine?
glucose, ketones, nitrites, protein and leukocyte esterase.
Signs and symptoms of a UTI
cloudy, foul smelling urine, burning, urgency.
LABS: positive leukocyte esterase, nitrites, rbc, sediment.
What does a culture and sensitivity do?
Identifies the type of bacteria and what antibiotic will kill it
What is important when taking care of a patient with a UTI?
get urine sample first, then admin broad spectrum abx
Why do we send patients home on broad spectrum abx?
C/S takes 24-72 hours to get back and want them to start on a medication before leaving. Once results come back, we can change to a specific abx.
What does a 24 hour urine collection measure?
creatinine, urea nitrogen, sodium, chloride, calcium, catecholamines and proteins.
A 24 hour collection for creatinine clearance measures what?
gfr for clients who have impaired kidney function
Client education for 24 hour collection
void before timer starts
every drop needs to enter the collection container
Start over if a drop does not enter
clean catch urine collection, client education?
do not touch inside of the cup.
Wipe, void, then void into cup.
A renal ultrasound is used to?
assess kidney size, assess ureters, bladder, massess, cysts, calculi, and obstructions in the lower urinary tract.
Nursing actions for ultrasound
preform skin care by removing gel after the procedure
Complications? minimal risk for client
CT scan is used for?
3D imaging of the renal/urinary system to assess for kidney size and obstruction, cysts or masses.
Ct scan can use what?
contrast media to enhance images
Nursing actions for CT scan
Does not use bowel prep. Same as KUB, but with the use of contrast media
Complications for CT
Media can cause acute kidney injury.
risk for complications increases for clients who are: older, dehydrated, history of previous renal insufficiency, and taking nephrotoxic drugs.
Nursing actions for patients taking metformin getting a ct with contrast
stop before procedure, and start back after kidney function returns to normal
MRI is used for?
staging cancer, similar to CT
MRI nursing actions
clients lay down and need to remain still throughout the test
Metal implants are not allowed in the machine
MRI complications
poor imaging if client is unable to lie still
X-ray KUB looks at what?
kidney, ureters and bladder: visualizes the structures of these areas and detects calculi, strictures, calcium deposits, and obstructions.
Cystoscopy/ Cystourethroscopy does?
discovers abnormalities of bladder wall and or occlusions of ureter or urethrea.
Cystoscopy/ Cystourethroscopy pre procedure?
NPO after midnight
admin laxative or enema night before for bowel prep.
Cystoscopy/ Cystourethroscopy post
monitor vs and urine output
document color (can be pink tinged).
Irrigate cath with normal saline
irrigation if blood clots are present or urine is absent/ decreased.
encourage fluids to increase urine output to reduce burning sensation
Cystoscopy/ Cystourethroscopy complications
UTI: cloudy, foul odor, urgency, frequency, burning.
IV Pyelogram does what?
identifies obstruction or strucutural disorders of the ureters and renal pelvis of kidneys through instilling contrast media.
Iv pyelogram identfies what?
fistulas, diverticula, and tumors in the bladder and urethra, during a cystoscopy.
obstruction in the renal pelvis or ureter
Pre and post/ complications for iv pyelogram
same as cystoscopy
Renal scan assess what?
renal blood flow and estimates gfr after iv injection of radioactive material to produce scanned image of kidneys
Renal scan pre/post procedure
-Assess bp frequently during and after if patient received captorpril (changes blood flow to kidneys).
-Increase fluids if hypotension occurs to promote excretion of the radioactive materials.
alert clients of orthostatic hypotension
Complications of renal scan
Radioactive material does not cause nephrotoxicity and are not at risk from the material they excrete in the urine.
Kidney biopsy is done for what?
removing a sample of tissue from the kidney for examination
Kidney biopsy pre
Review coagulation studies
Ensure client has been NPO 4-6 hrs before
Kidney biopsy post
Monitor vs following sedation
Assess dressings and urinary output(hematuria)
Review hgb, hct values
Admin analgesics prn
Kidney biopsy complications
Hemmorrhage, and UTI
Hemorrhage signs and symptoms
SOB, tachycardia, tachypnea, pallor, cool skin,
Lithotripsy is used for what?
to break up stones
Lithotripsy pre/post
pre: obtain consent, flat position, anasethetic 45 mins prior, assess for gross hematuria
Post: strain urine, monitor site
Lithotripsy complications
bruising and flank pain at side procedure was done atand dysrhythmias.
Ureterolithotomy and Nephrolithotomy is used when?
surgery to remove kidney stones depending on the location of the stone. These are open surgeries
Ureterolithotomy and Nephrolithotomy pre procedure
NPO. bowel prep,
Ureterolithotomy and Nephrolithotomy post procedure
monitor for bleeding,
maintain fluids
initiate infection control measures
monitor for the passages of stone fragments.
symptoms/ assessment findings for UTI
lower back/ abdominal pain
urinrary frequency, urgency
dysuria, fever, nocturia, hematuria. Feeling of incomplete emptying
Diagnostics/tx and medications for UTI
Cystoscopy: complicated UTI
CT for pyleonphritis.
What will be ordered when a patient is suspected to have a UTI?
UA. C/S.
WBC count and differential: ureosepsis is suspected.
Patient education for UTI
3L of fluid a day
empty bladder every 3-4 hour
bathe daily to promote good hygiene
drink cranberry juice
urinate before and after intercourse.
What conditions are included in UTI?
cystitis, urethritis, prostatitis
What bacteria usually causes a UTI?
e.coli
staph can also lead to it, but most common is e.coli
Why are women more at risk for getting a UTI?
urethra being closer to the anus
What can happen if a UTI is left untreated?
can lead to pyelonphritis and ureosepsis which can lead to death.
Older adults manifestations of UTI
confusion, incontinence, loss of appetite, nocturia, dysuria, hypotension, tachycardia, tachypnea, and fever
Lab values for UTI
Bacteria, sediment, wbc, rbc, positive leukocyte esterase and nitrites (68%-88%) positive results indicates UTI.
WBC >10,000 and increased neutrophils
Medications for UTI
Fluoroquinolones, nitrofurantoin, trimethoprim, sulfonamides
If admin a sulfa we need to ask client for an allergy to what?
sulfa
When clients are taking a flurorquinolones or sulfa, we should explain to them?
sunburn is a risk and take with a full glass of water.
Patient medication education
take full abx, take with food, monitor and report watery diarrhea that can be c. diff
What is Phenazopyridine and what is important to teach the patient?
bladder analgesic used to treat uti.
-turn urine orange, take with food,
DOES NOT TREAT INFECTION, just the symptoms.
How should female clients take care of themselves to decrease risk of UTI?
wipe the perinel area from front to back.
avoid bubble baths and perfume feminine products.
avoid sitting in wet bathing suit
avoid tight clothing
Nursing care for UTI
warm sitz bath 2-3 times a day to provide comfort
avoid caths
pregnant individuals need to be treated asap as this can turn to pyelonephritis.
Most common type of Renal calculi
calcium phosphate or calcium oxalate.
What is the most common cause of kidney stones?
dehydration (especially in older adult clients)
Assessment findings and symptoms of kidney stones
severe pain. Intensifies as stone moves
flank pain
frequency dysuria, fever,pallor, diaphoresis, nausea and vomitting
hematuria,
Lab test for kidney stones
UA
Lab values for kidney stones
increased RBC, WBC, bacteria, crystals, increased urine turbidity if infection is present.
Decreased ph: uric acid, cystine stones
Increased ph: calcium or struvite stones
diagnostic procedures for kidney stones
x-ray, ct. mri of abdomen and pelvis, renal ultrasound or cystoscopy.
Nursing care for kidney stones
strain all urine to check for passage of calculus and save for lab analysis.
3L fluid a day unless contra
Encourage ambulation
Monitor when client is passing stones
monitor for pain, urinary ph, intake and ouput.
Medications for Kidney stones
opioids, NSAIDS, Spasmoltyic medications, ABX
Opioid kidney stones
watch for respiratory depression. Can be used for the first 24-36 hours with acute onset of calculi.
NSAIDs for kidney stones
Ketorolac: moderate pain, fever and inflammation.
risk for decreased renal function and perfusion.
Nursing action: observe for bleeding
Patient: watch for bleeding, Dark stool, blood in stool
notify provider if abd pain occurs (gastric ulceration)
Spasmoltyic medications, Kidney stone
Oxybutynin alleviates pain by decreasing bladder spasms.
Nursing action for Oxybutynin
assess for history of glaucoma (oxy can increase icp)
monitor for dizziness and tachycardia, and monitor for urinary retention
Client education for Oxybutynin
report palpitations, and problems with voiding or constipation
-dizzy, dry mouth are common
Suck on hard candies.
ABX kidney stones
-admin with food and monitor for nephrotoxicity and ototoxicity for clients taking gentamyocin.
Client education
-Urine can have foul odor because of this medication
-report loose stool
Diagnostic/ tx for kidney stones
lithotripsy, retrograde ureteroscopy, open surgery nonsurgical chemolysis
What is nonsurgical chemolysis?
uses chemicals to break the stones up.
What are the types of open surgeries for kidney stones?
ureterolithotomy: ureter
Pyelolithotomy:kidney pelvis
Nephrolithotomy: in kidney
Client education for calcium phosphate stones
limit intake of food high in animal protein, sodium and reduce calcium intake.
Calcium oxalate
avoid oxalate sources: spinich, black tea, rhubarb, cocoa, beets, pecans, strawberries, peanuts, okra, chocolate, wheat germ, lime peel, swiss chard
limit sodium intake
Struvite education
avoid high phosphate foods, dairy products, red and organ meats and whole grains.
Uric acid education
decrease intake of purine sources, organ meats, poultry, fish, gravies, red wine, sardines
consume lemon or orange juice to alkalize the urine.
cystine education
limit animal protein intake
Hydronephrosis occurs when?
a calculus has blocked a portion of the urinary tract. The urine backs up and causes distention of kidney leading to permanet kidney damage.
Nursing actions for Hydronephrosis
notify provider immediately, prepare client for removal of stones.
Hydronephrosis vs hydroureter
obstruction is in the ureter rather than in the kidney
What is hydroureter
enlargement of the ureter
common causes of urinary obstruction
kidney stones, tumors, fibrosis , structure abnormality
treatment and diagnostic for hydronephrosis
Lab findings for someone with hydronephrosis or hydroureter
-bacteria or white blood cells
if infection is present
-microscopic examination may show tubular epithelial cells
-blood chemistries normal unless GFR is decreased (which will increase BUN and creatinine)
-elevated K+, potassium, phosphorus, and calcium
-metabolic acidosis
Primary problems associated with hydronephrosis and hydroureter
infection and urinary retention
urinary outflow obstruction can be seen with
ultrasound or CT
Patient education for hydronephrosis
What is polycystic kidney disease?
congenital disorder where clusters of fluid filled cysts develop in the nephrons
Is PKD hereditary?
yes and is more common in caucasian clients
Expected findings in PKD
anxiety, guilt, abd pain, flank pain, headaches, enlarged abd girth, constipation, bloody/cloudy urine, renal lithiasis, progressive kidney failure, nocturia.
lab findings for PKD
hyponatremia, increased BUN, Creatinine, creatinine clearance
diagnostic procedures and lab test
ua, ultrasound, ct/mri
Nursing care for PKD
Hypertension control: highest nursing priority.
pain: analgesics, relaxation, deep breathing, use NSAIDs cautiously.
Infection: admin abx, evaluate blood creatinine levels and urinary output. monitor specific gravity
Client education for PKD
monitor bp and weight daily
notify provider if elevated temp
adhere to low sodium diet.
What is uremia
buildup of nitrogenous waste products in the blood as a result of kidney failure
symptoms of uremia
anorexia, N and V, muscle cramps, pruritus, fatigue, lethargy
What should we observe near the costovertebral angle
asymmetry or discoloration,
We should auscultate the renal artery for any
bruits (swooshing noises)
What can a bruit indicate
renal stenosis
When a distended bladder is percussed, it often sounds
dull
How to perform bladder percussion
percussion the lower abdomen and continue in the direction of the umbilicus until dull sounds are no longer heard
If a patient reports flank pain or tenderness, should we percuss this section first?
NO! start with non-tender
How to assess the urethra
using a good light source, inspect meatus and area around it
we should teach females to wipe from
front to back to decrease risk of infection
when is serum creatinine produced
when muscle and other proteins are broken down
Why do males tend to have a slightly higher creatinine level than women
have more muscle mass
when the serum creatinine level is doubled, what does this indicate in GFR
it’s reduced by 50%
What is the only disease that will increase creatinine
kidney disease
a decreased creatinine level can indicate
decreased muscle mass
BUN measures the
effectiveness of urea nitrogen excretion (byproduct of muscle breakdown in the liver)
does an increase BUN always indicate kidney disease
no
what are other diseases that can cause an elevated BUN level
rapid cell destruction from infection, cancer treatment, steroid therapy
If liver dysfunction is present, are urea nitrogen levels decreased or increased
decreased because the liver failure limits urea production
what is the blood urea nitrogen to serum creatinine ratio
comparison of levels of BUN to test other non-kidney related factors
elevations to both serum creatinine and kidney disease indicates
kidney dysfunction not related to dehydration or poor perfusion
What does cystatin c measure
glomerular filtration rate
What does cystatin-c
protein produced by nucleated cells in the body. produced at a constant rate
When glomerular filtration rate decreases, does cystic-c increase or decrease
increase
Blood osmolarity is a measure of
overall concentration of particles in the blood
blood osmolarity is a good indicator of
hydration status
when blood osmolarity is decreased, what occurs with vasopressin
its release is inhibited
When blood osmolarity increases , vasopressin is
released
what is microalbumineria
presence of albumin in the urine that is not measurable by a urine dipstick or usual urinalysis procedures
Treatment for hydronephrosis and hydroureter
-caused by stone : cystoscopic or retrograde urogram procedures
-caused by stricture (hydronephrosis): nephrostomy is performed
with hydronephrosis, we may see damage to kidney tissue, as well as
kidney necrosis and fluid + electrolyte imbalances
difference between external and internal nephrostomy tube
external drains fluid outside of body, internal can drain fluid outside of body or can drain some into the bladder to pee out
Patient preparation for nephrostomy
NPO 4-6 h b4, PT/INR/PTT should be normal, drugs used to relieve hypertension, moderate sedation
Procedure of nephrostomy
prone position, soft - tipped guide wire is placed through needle and then a catheter is placed over wire, catheter remains in place to drainage bag
Post surgical care for nephrostomy
-assess amount of drainage in collection bag h for 24 h
(if drainage decreases and patient has back pain it can indicate the tube is dislodged)
-monitor site for leaking or blood
-drainage may contain blood for 12-24 h, then it should be clear
-irrigate with 5 ml normal saline to check potency and dislodge clots
-diuresis can occur so monitor for s/s of dehydration
-assess for infection
When else may a nephrostomy tube be used
with renal calculi to prevent stone from passing
How often do we drain nephrostomy tube
4-5 times / day
How often do we change drainage bag
3 times week
When do we change dressing for nephrostomy tube
q other day, 2x/week, when soiled
What are reasons we may have zero urine output from nephrostomy tube
kinks, stone, pulled out
What complications should we monitor patient for after nephrostomy
decreased/absent drainage, cloudy or foul smelling drainage, leakage of blood or urine from site, back pain
What is pyelonephritis
urinary tract infection that spreads from the bladder to the kidneys
acute pyelnephritis
results from active bacterial infection
chronic pyelonephritis
occurs from repeated UTIs caused by obstruction, reflux, structural deformities, tumors, spinal cord issues, DM
What is reflux
back flow of urine toward the kidney… increases risk of pyelonephritis
Symptoms of acute pyelonephritis
acute tissue inflammation, local edema, tubular cell necrosis, possible abscess
What are kidney abscesses, a complication of pyelonephritis
pockets of infection
Symptoms of chronic pyelonephritis
fibrosis and scar tissue –> leading to impaired filtration, reabsorption, and kidney function
What bacteria is the most common cause of UTI
e-coli
Who most commonly gets acute pyelonephritis
young female who is sexually active, women in 2nd-3rd trimester
Symptoms of acute pyelonephritis
fever, chills, tachycardia, tachypnea, colicky abdominal discomfort, N/V, burning/urgency/frquency with urination, CVA tenderness, flank/back/loin pain, recent UTI
Symptoms of chronic pyelonephritis
HTN, hyponatremia, nocturia, hyperkalemia, acidosis
Assessment of someone with suspected pyelonephritis includes
-inspecting the flanks and palpating CVA
-inflammation: enlargement, asymmetry, edema/redness, hyperpigmentation,
Why should we do a psychosocial assessment on someone with suspected pyelonephritis q
often get embarrassed and upset that it may have to do with sexual activity
Laboratory assessment findings with pyelonephritis
- UA: positive leukocyte esterase and presence of WBC and bacteria and RBC and protein
- CBC with differential, C-reactive protein, ESR
-BUN and creatinine (increased)
-GFR
Imaging used with pyelonephritis
X-ray of kidneys, ureter, bladder (KUB)
CT (abscesses, fluid accumulation, inflammation)
voiding cystourethrogram (reflux)
Other diagnostic assessments with pyelonephritis
-antibody-coated bacteria (to see if they need long-term antibiotic therapy)
-testing for certain enzymes (kidney tissue deterioration)
-radionuclide renal scans (active pyelonephritis or abscesses)
- kidney biopsy
nonsurgical interventions for pyelonephritis
acetaminophen (pain), antibiotics (brand then narrow), catheter replacement, nutritional therapy (adequate calories from all food groups and 2L fluid/day)
Surgical management of pyelonephritis
pyelolithotomy (removal of stone from kidney), nephrectomy (removal of kidney), ureteral diversion, reimplantation of ureters to restore proper drainage, ureteroplasty (ureter repair or revision) , ureteral reimplantation
Patient teaching for pyelonephritis
importance of finishing ABX therapy, importance of regular follow-up visits, blood pressure control (to slow kidney dysfunction), importance of adequate fluid intake
What is glomerulonephritis
immune disorder of the kidney (could result from lupus, inflamed glomeruli)
Acute glomerulonephritis occurs quickly 10 days after tis kind of infection
strep
Physical assessment for acute glomerulonephritis
-inspect for cuts/lesions (including new jewelry)
-assess for edema
-ask about SOB
-listen to lungs (crackles) and s3 heart sound and distended neck veins
-smoky-reddish/brown urine
-dysuria or oliguria
-weights for fluid retention
-anorexia, N/V, fatigue
What will the UA of someone with acute GN show
hematuria, proteinuria, red blood cell casts
Why is a 24 hour urine sample needed in someone with suspected acute GN
assess for presence of protein (may be 3g/ 24h)
Will serum albumin levels be increased or decreased in someone with acute GN
decreased (its being peed out)
will GFR be increased or decreased in a patient with acute GN
decreased
What diagnostic tool may be used to diagnose acute GN
kidney biopsy
Nursing interventions for patient with acute GN
-manage infection with proper abx (penicillin, erythromycin, azithromycin)
-stress personal hygiene (handwashing)
-corticosteroids (to suppress inflammation)
How to prevent complications of acute GN
-fluid overload, HTN, edema = diuretics and sodium and water restrictions
-restriction of potassium and protein to prevent hyperkalemia and uremia (as result of elevated BUN)
-anti-hypertensive drugs
For a patient with acute GN, when may dialysis be needed
-uremia or fluid overload cannot be treated with nutrition therapy and fluid management (symptoms of uremia include N/V/anorexia)
How to reduce emotional stress in client with acute GN
relaxation techniques, and diversional activities
Patient teaching for acute glomerulonephritis
-purpose of taking drugs
-diet and fluid restrictions
-daily weights and BP and notify of any sudden increases
-
What is rapidly progressive glomerulonephritis (RPGN)
presence of crescent-shaped cells in the bowman capsule , often progresses to end-stage kidney disease
Symptoms of RPGN
fluid volume excess, HTN, oliguria, electrolyte imbalances, uremic symptoms
What is chronic glomerulonephritis
develops over years or decades
What are the symptoms of chronic glomerulonephritis
mild proteinuria, hematuria, HTN, fatigue, occasional edema
During chronic glomerulonephritis, what happens to the kidney tissue
atrophies, functional nephrons greatly reduced, glomerular changes in late stages
What occurs from the loss of nephrons in chronic glomerulonephritis
reduces glomerular filtration –> proteins enter urine -> ESKD
What is a common assessment finding with chronic glomerulonephritis we should assess for
nocturia, dyspnea (due to fluid overload), decreased urine output, changes in cognition and memory (due to waste buildup in blood)
Physical assessment findings of chronic glomerulonephritis
systemic circulatory overload (crackles, SOB, increased weight, HTN, venous distention) uremic symptoms (slurred speech, ataxia, tremors, asterixis) yellow color to skin, bruises, rashes, dryness, itching
Diagnostic assessment findings for chronic glomerulonephritis
-urine output decrease
-fixed urine specific gravity despite fluid intake
-red blood cells,
-red blood cell casts,
-GFR is low
-elevated serum creatinine
-BUN increased
What can happen with sodium levels with chronic glomerulonephritis
retention of sodium, but heavily diluted plasma shows abnormally low sodium levels
electrolyte imbalances found in chronic glomerulonephritis
hyperkalemia hyperphosphatemia
acidosis
How do kidneys appear on x-ray or CT with chronic glomerulonephritis
small
Management of chronic GN
diet changes, fluid intake sufficient to prevent reduced blood flow to the kidneys, drug therapy to control problems from uremia
Eventually, chronic glomerulonephritis
dialysis or transplantation
Example of short and long bones
short: phalanges
long: femur
The red bone marrow makes
red blood cells
The yellow bone marrow makes
fat cells
What are the bone forming cells?
osteoblasts
What are the bone destroying cells
osteoclasts
How many bones do we have
206
What are the functions of the musculoskeletal system
protect vital organs, store calcium
Calcium and phosphorus have an ______ relationship
inverse
What does PTH hormone do
stimulate the release of calcium from the bone to raise serum calcium levels (stimulates bone resorption)
What does calcitonin do
decrease serum calcium by decreasing bone resorption
A body’s decrease in vitamin D level can result in ______ in the adult
osteomalacia (softening of bone)
Estrogens stimulate ____ activity and inhibit ______.
osteoblastic ; PTH
When estrogen levels decline at menopause , women are susceptible to
osteoporosis
What is arthritis
joint inflammation
what is synovitis
synovial inflammation
When does muscle atrophy occur
prolonged immobility, not regular exercise, aging
tendons attach
muscle to bone
ligaments attach
bone to bone
older adults, especially women, have bone density loss known as
osteopenia
osteoporosis can cause
kyphosis and gait changes (these changes predispose the person to fractures)
What are things that can result from prolonged immobility
risk for bed sores, skin breakdown, blood clots, pneumonia, muscle atrophy , decrease ROM, contractures
Can contractures be permanent?
yes
CT is very useful for detecting musculoskeletal conditions in which places
vertebral column and joints
Before CT, the nurse should asses the client for which allergies
iodine- based contrast
Why is MRI used for most musculoskeletal disorders
more accurate than CT for spinal and knee problems, most appropriate for viewing joints and small tissues
What is an magnetic resonance athrography (MRA)
MRI with contrast injected into the joint
What is an arthroscopy
tube inserted into joints for direct visualization; may be used as a diagnostic or a surgical procedure
Patient prep for arthroscopy
-pt must have mobility
- ROM exercises may be taught
Nursing safety priority for arthroscopic procedure
neurovascular status: distal pulses, warmth, color, capillary refill, pain, movement, sensation of affected extremity
Follow-up care for arthroscopy
-encourage client to perform exercises
-mild analgesic (acetaminophen) for diagnostic
-opioid analgesic for surgery
- ice for 24 hours
- elevate extremity 12-24 hours
Complications of arthroscopic procedure
swelling, severe joint or limb pain, thrombophlebitis, infection
What is carpal tunnel syndrome
disease where we have compression of the median nerve, causing pain and numbness
What are causes of carpal tunnel syndrome
typing, repetitive movements, cell phone use
Symptoms of carpal tunnel syndrome
‘pins and needles’ sensation in first three fingers and thumb side of ring finger
Assessment findings of carpal tunnel syndrome
positive Phalen’s maneuver test, atrophy, swelling, skin discoloration, brittle nails, increased/decreased hand sweating
Treatment for carpal tunnel syndrome
Nonsurgical: NSAIDs, corticosteroid injection, immobilization, yoga
Surgical: CTR surgery
Nursing care following surgery for CTS
-neurovascular health assessments
-dressing checks
-exremity elevation
-analgesics
-hand movements restricted 4-6 weeks
Patient education for CTS
-chair height, wrist rest devices, short breaks from repeotive activities, stretch fingers and wrists
-chronic and will likely need surgery again
Nurses should recognize that those with CTS are at risk of
injury, and decreased ability to perform ADL’s
What is important to review in a history of a women?
Menopause
Why should we pay attention to menapause?
Decreased estrogen can increase risk for fractures and the development of osteoporosis.
In older adults who have kyphosis what do we worry about?
Falls because they are off center.
What can kyphosis impaire?
Breathing, leading to decreased profusion, gas exchange and pooling of secretions
Kyphosis puts patients at risk for?
Pneumonia because of the pooling of secretions
Diabetics are at risk for foot ulcers because?
they have decreased sensory perception deficit.
What kind of lifestyle impairs the musculoskeletal system?
Seditary lifestyle can increase blood clts, muscle atrophy because of immobility.
what profession is at risk for getting injured?
construction workers or individuals who work around chemicals.
Why would an allergy to dairy cause issues with the musculoskeletal system?
If they are not consuming enough calcium they can have hypocalcemia.
Can steroids affect calcium level?
yes
Should an injury ever effect your pulse?
NO
What is involved in a musculoskeletal assessment?
Review of patients history, age, pain, assess skin, and muscle strength, assess gait and general mobility, assess pulses
What is a complete fracture?
Fracture through the entire width of the bone
What is an incomplete fracture?
bone does not divide
What is a closed fracture?
no visible wound, does not break the skin
What is a open or compound fracture?
fracture that breaks through the skin surface
What is a simple fracture?
One fracture line
What is a comminuted fracture?
Multiple fracture lines, bone in multiple pieces
What is a displaced fracture?
Bone fragments not in alignment
What is a non-displaced fracture?
Bone fragments remain in alignment
What is a pathologic (spontaneous) fracture?
fracture that occurs due to underlying disease
What is a fatigue or stress fracture?
Excessive strain to that area of the body. Most commonly occurs in the foot from running or jumping. Also known as a hairline fracture
What is a compression fracture?
Fractures that occur in older adults with osteoporosis.
Stages of bone healing
1- hematoma forms
2-granulation tissue –> fibrocartilage (foundation for bone healing)
3- vascular and cellular proliferation (callus)
4- callus transformed into bone
5- consolidation and bone remodeling
What nutrients are needed for production of new bone
calcium, phosphorus, vitamin D, protein
What are complications of fractures?
VTE, Dvt, pe formation
Infection
Compartment syndrome
Fat embolism
If a patient has a open fracture, what can this increase their chance for?
infection
What is compartment syndrome?
Increase pressure within a closed compartment that results in impaired circulation
Compartment syndrome is considered what?
a medical emergency
What is the procedure used to fix compartment syndrome?
Fasciotomy.
Symptoms of compartment syndrome?
pain, paleness, pulselessness, parasthesia, paralyzed.
What is the first sign of compartment syndrome?
Parasthesia (numbness and tingling). The other 4 will follow after this sign
When assessing a patient with an injury, it is important to assess them how?
above and below the injury location. Assess skin for warm and pinkness with no impaired pulse. Bilaterally.
If a patient has a dressing and develops compartment syndrome what is the nursing intervention we should do?
cut the dressing off and notify provider.
When assessing pain, what should we try first?
non pharmacological interventions. Deep breathing, guided imagery, distraction, positioning, breathing, ambulation
What is avascular necrosis?
causes bone death, most common in hip fractures
Chronic pain can only be assessed by?
subjective data
Infection (osteomyelitis) happens when?
Osteomyelitis is a severe and difficult infection to treat. It is an infection in the bone most often caused by bacteria.
Pathophysiology of Osteomyelitis
Inflammatory response is initiated that allows for capillary leakage and swelling in that area. This can lead to drainage from the actual wound or puss depending on the type of wound.
Bone becomes ischemic and leads to bone death.
What can happen during osteomyelitis?
bone will regnerate before treatment is complete, laying new bone on top of the infected bone causing a prolonged infection and making it harder to treat.
Osteomyelitis can be
acute or chronic
What is the difference between acute and chronic Osteomyelitis
With acute, it is treated and is resolved.
With chronic: treatment is not long enough lasting in an infection of 3 months or longer.
Most common ways osteomyelitis occurs?
Break in the skin, stabbing, open fracture, ANIMAL BITE., or if diabetics get a foot ulcer and bacteria enter the bone.
What is the difference between acute and chronic osteomyelitis symptom wise?
acute: fever swelling, heat, bone pain, erythmia
Chronic: no fever and localized pain.
Which bacteria most likely is the cause of osteomyelitis?
staph
What is the most common cause of MRSA infection?
Surgical infections. (external fixator and open reduction)
Education for patients with open wounds
infection prevention
understanding how to maintain any open wounds
monitor for signs and symptoms of infection.
know how to do iv abx at home.
Patients on ABX for MRSA and osteomyelitis should be educated on what when taking ABX?
Because of the prolonged period of time taking ABX, patient should be educated that they may develop a superinfection (C.DIFF).
How many stools a day should a patient report for suspicion of c.diff?
10-15 a day and describe as explosive
diarrhea is common but if having 10-15 a day alert provider
Medications used to treat MRSA?
Vancomycin, daptomycin, linezolid.
Opioids and NSAIDs can be used in conjunction to?
reduce pain and promote wound healing
Fat embolism
Fat globules released from yellow bone marrow 12-48 hours after the injury has occured.
Pathophysiology of Fat embolism
Clog small vessels that supply blood to our organs. The lungs are mostly effected.
Nursing interventions for fat embolism
Supportive care, o2 management, and monitor symptoms.
Early indication of fat embolism
hypoxemia, sob, increased rr
Progressed symptoms of Fat embolism
changes in LOC
What is distinctive in fat embolism
Petechiae found over the trunk, last symptom to develop in fat embolisms.
How to diagnose a fat embolism?
chest x-ray, ct, mri
Fractures can cause fat embolisms how
yellow bone marrow contains fat and when it breaks it can cause bits of fatty tissue from inside of the bone to enter the blood stream which can travel to respiratory system.
Treatment for fat embolism
immobilize the fracture, bed rest, o2, fluids.
Are dvt/pe and fat embolisms the same?
yes, the difference is the petechiae seen in fat embolisms.
two types of casts
fiberglass and plater
Plaster casts take how long to form?
24 hours to dry before they become rigid.
Education for patient with placement of plaster cast?
as the cast is forming it will have musty smell, but once it drys it will be odorless.
be careful not to damage the plaster while its drying because it is not rigid.
Fiberglass forms how?
becomes rigid quickly to immobilize a joint or bone.
assessment for the types of casts
check above and below the cast
assess skin for warmth, dry, pink skin and intact
Check thumbsite for fiberglass cast.
capilarry refill
wiggle fingers and toes
assess pulses.
check places that irritation may occur.
If there is an odor after 24-48 hours after a plaster cast as been placed, what does this indicate?
infection.
Patient education for fiberglass cast?
do not stick stuff under your cast, as this can tear the skin and cause an infection where it can not be seen.
Cast removal patient education
do not scrub the area, allow it to soak
gradual exercise
weakness may be present
if a patient has a wound under cast, what can we do?
cut a section in the cast to preform wound care.
Nursing interventions for prevention of musculoskeletal problems with aging?
weight bearing exercises/ how to prevent falls/adequate intake of calcium and vitamin d (decreased bone density)
body mechanics, assistive walking devices, supportive shoes (kyphosis)
regular physical examinations
apply warmth (osteoarthritis)
decreased ROM (assess ADL’s)
What is important to remember with bucks?
skin integrity can become impaired because of the pulling of the skin from weights.
Weight amount for bucks
5-10 lbs
Nursing reminders for tractions?
do not manually lift the weights unless ordered too
ALWAYS NEED TO BE FREE HANGING
Document: skin integurity, profusion and color.
Skeletal differs from Bucks how?
allows for more weight, pins go through the bone and weight pulls on the bone.
15-30lbs weights
Bucks is used for?
femur and hip fractures
Skeletal puts the patient at risk for?
infection
Nursing intervention and care for skeletal?
pin care is now added with skin assessment and care.
What does free hanging mean?
they are not resting on the floor, bed, or bed frames.
What is ORIF
open reduction with internal fixation.
surgical placement of pins and rods inside the patient
at risk for infection now
What is OREF
surgically placed
OREF requires?
pin care for infection prevention
pre-op considerations for fixators?
obtain consent, npo, anasthesia
Post op education for patients with surgically placed fixators
Understand how to do pin care at home and monitor for signs and symptoms of infection and infection prevention.
Difference between strain and a sprain
Strain is muscle or tendon; falls, lifting, and exercise
sprain is ligament ; twisting from falls, sports activity
management of strains
Cold and heat, anti-inflammatories, muscle relaxants, surgical repair if needed (3rd degree), activity limitations
m
management of sprains
RICE, immobilization, surgery if severe
Emergency care for an extremity fracture?
immbolize, pressure,, call 911.
Decreased pth leads to
hypocalcemia.
Hypercalcemia puts patients at risk for
fracutres
Phosphorus is low
calcium can be high, at risk for fractures
Calcitonin high
calcium is low
Vitamin d activation
activated in kidneys, absorbed in the intestines
Vitamin d and calcium
vitamin d makes it possible for intestines to absorb calcium.
If we can not find a pulse and assess it correctly what should we do?
obtain a doplar to assess the pulse
Amputations can be either
elective or traumatic
What is an example of an elective amputation
a diabetic patient choosing to remove toe after infection
Traumatic amputations are more likely to be seen
in the community
What should you do if you witness a traumatic amputation in the community
- call 911 2. ABC’s 3. find dry (preferably sterile) gauze or clean cloth and put on limb, elevate above heart level and hold pressure
Should you remove the the cloth to check for bleeding during a traumatic amputaion?
no
What should we do to preserve the body part after amputation
preserve the limb by wrapping in gauze and placing it in a bag, put digit in ice water solution, keep dry but cold
what is phantom limb pain
pain that occurs where a limb is absent
For phantom limb pain, what psychosocial needs should be met
validating and acting on their pain, “Where is your pain located at”
What treatments options can be used for phantom limb pain?
-IV calcitonin
-Beta-blockers (dull burning)
-Gabapentin (knife, sharp nerve pain)
-TENS unit
-Antispasmodics (spasms)
Why do we give IV calcitonin during first few weeks after amputation
can reduce occurrence
How long do we elevate limb following amputation
24 h
Nursing interventions following amputation
-compression dressing
-observe for bleeding/infection
-assess pulses
-assess skin breakdown
-prevent contractures
What assessments should we perform on clients with amputation
neurovascular, cap refill, psychosocial (amputee and caregiver/family grieving)
What is a neuroma
complication of amputation; tumor at end of nerve cells, most often in upper extremities amputation
Treatment for neuroma
removal (may come back afterwards and present with more pain), peripheral nerve blocks, steroid injectors
What is a flexion contracture
-biggest complication of hip or knee amputation
-these patients are not a candidate of prosthetic device
Nursing interventions for preventing flexion contractures
ROM exercise, turn q 2 hours and independently, firm mattress, do not elevate after 24 Horus , push residual limb down into the bed
How often should our amputee patients lay prone to prevent flexion contracture?
20-30 min q 3-4 h
what wrapping method do we use with prosthesis to help shape stump?
figure 8
What is an arthroplasty
surgical removal of a diseased joint due to osteoarthritis, osteonecrosis, ra, trauma, or prosthetics.
Pre procedure for Arthroplasty
CBC, urinalaysis, electrolytes, bun, creatinine. Assess for surgical readiness and rule out anemia, infection and organ failure.
chest x-ray and ecg.
Post procedure for arthroplasty
extensive physical therapy
monitor for incisional infection
care for the incision
monitor for dvt and pe
Complications from arthroplasty?
Vte, dvt. pe, joint discoloration, infection, anemia, neurovascular compromise.
What can an arthroplasty put the patient at risk for?
DVT, and incision infection.
What is a total joint arthroplasty?
Total joint replacement, involves replacement of all components of an articulating joint
What is a total knee arthroplasty?
Involves replacement of the distal femoral component, tibia plate, patellar button.
This is a surgical option when conservative measures fail
What can be perscribed weeks before an arthroplasty to raise the hemoglobin level to prevent anemia?
epoetin alfa
What is a contraindication to arthroscopy?
uti, arterial impairment, uncontrolled diabetes, hypertension, cardiac disorders (dysrhythmia)
Client education for a Arthroscopy
scrub the surgical site the night before surgery to decrease bacteria count on skin which helps lower the chance of infection
why are older adult clients at higher risk of developing dvt and pe after arthroplasty?
compromised circulation and their age
Nursing actions for post arthroplasty?
monitor for bleeding
maintain aseptic technique
monitor incision site for infections
follow prescriptions monitoring mobility, and positioning to protect joints and prosthetics
assess neurovascular status of operative extremity.
