Unit 1 Flashcards
This organ is considered extremely vascular with an associated high risk for hemorrhage
** Blood volume circulates 12 times in one hour through this organ **
Kidneys
What are the functions of the kidneys?
** Remember A WET BED **
- A (Acid-base balance - excretes acidic substances/regulation of bicarbonate)
- W (Water balance - creating urine to excrete)
- E (Electrolyte balance - potassium, sodium, phosphorus, calcium)
- T (Toxin removal - Dialysis is needed if toxins can’t be removed)
- B (Blood pressure control - RAAS)
- E (Erythropoietin - stimulates bone marrow to create RBCs *anemia can occur with kidney dysfunction)
- D (Vitamin D metabolism - activates vitamin D for the body to use, which helps with calcium absorption)
What is the end goal of the renin-angiotensin aldosterone system (RAAS)?
Increased BP and sodium/water retention
What kind of mechanism does RAAS act as?
RAAS acts as a negative feedback mechanism (once the end goal has been met, the process will stop).
What are the conditions that signal decreased tissue perfusion and activate RAAS?
- Low blood pressure
- Low blood volume
- Low blood sodium
- Low blood oxygen
Is urine output increased or decreased with RAAS?
Urine output is decreased due to water and sodium retention
What are the normal value ranges for serum creatinine?
Males: 0.6 - 1.2 mg/dL
Females: 0.4 - 1.0 mg/dL
What is the normal value range for serum blood urea nitrogen (BUN)?
8 - 20 mg/dL
What is the normal value for BUN to creatinine ratio?
About 1:1
What is the normal value range for urine specific gravity?
1.005 - 1.025
What is the normal value range for creatinine clearance?
Varies based on age and gender
What is the normal value range for glomerular filtration range (GFR)?
90 - 120 mL/min
Which renal lab test is the best indicator of renal function/dysfunction?
Creatinine
- This lab value will follow and align with creatinine.
- Not as accurate at determining extent of kidney damage; other causes can make levels higher or lower (malnutrition can cause low levels)
Blood Urea Nitrogen (BUN)
This lab value helps in differentiating between prerenal and intrarenal causes of kidney dysfunction
BUN to creatinine ratio
This lab value is an indicator of how concentrated the urine is.
Urine specific gravity
- This lab value requires a 24-hour urine sample
- Indicates how effective the kidneys are at filtering out creatinine.
- Can be used to estimate the GFR
Creatinine clearance
This lab value indicates how quickly the kidneys are filtering.
** Values will be decreased in those with kidney damage
Glomerular Filtration Rate (GFR)
- Occurs when there’s an excess of crystal-forming substances that can’t be dissolved in urine
Contributing Factors:
- Disturbances in urinary pH
- Low urine volume
- Decreased fluid intake
- Dietary factors
Urolithiasis
What are the most common types of stones with urolithiasis?
Calcium oxalate
Calcium phosphate
Stones in this area of the renal system are usually asymptomatic and cause no obstruction to urine flow
Renal pelvis
Stones in this area of the renal system cause:
- increased pressure
- spasms of the smooth muscle lining
- distension of walls
- renal colic
- nausea/vomiting
Ureter
Stones in this area of the renal system cause:
- frequent/painful urination
- chronic discomfort
- hydronephrosis
- a decrease in renal function
- pyelonephritis
Bladder
Which dietary factors can contribute to urolithiasis?
- Too much calcium
- High animal protein in the diet
How does gout contribute to urolithiasis?
The increase of uric acid contributes to the formation of stones
What are the four types of stones with urolithiasis?
- Calcium (oxalate and phosphate)
- Struvite
- Uric acid
- Cystine
Which stones are seen in cases of infection (UTI)?
Struvite
What is the term for the pain that is experienced with urolithiasis?
Renal colic
Which type of diagnostic imaging test is needed to diagnose urolithiasis?
Non-contrast CT
** contrast damages the kidneys - if contrast is needed, adequate fluids need to be given before and after CT **
What other diagnostic tests are needed with urolithiasis?
- Blood work: hemoglobin and hematocrit levels will be low due to the sharp stones causing bleeding through the urinary tract.
- BUN and creatinine levels will be elevated (assesses damage to the kidneys)
- Electrolyte levels: kidney function is disrupted, causing fluctuations in the electrolyte levels
- UA: hematuria, nitrates, leukocytes
What are the nursing interventions for patients with urolithiasis?
- Pain assessment/control
- Encourage fluid intake: patients should intake 3-4 L/day to help flush the stones
- Strain the urine: stones need to be strained and sent to the lab to determine the cause.
- Ambulation: helps with the movement of stones
This medication is given if blood work or UA for urolithiasis shows an infection
Broad Spectrum Antibiotics (Piperacillin)
This medication specifically targets calcium stones
Chlorothiazide sodium ( thiazide diuretic)
what is the first line of treatment for urolithiasis?
Lithotripsy
What is the purpose of urinary stents?
To avoid damage to the ureter - catheters are placed to bypass the ureter and left in place for about 48 hours to allow time for the stone to pass
What is a sign that immediate medical attention is needed for those with urolithiasis?
Patient no longer feels pain and is not urinating.
This could be a complete obstruction, which could cause ischemia and renal failure
- Increase incidence in males
- Nausea & Vomiting
- Agonizing flank pain may radiate to: groin, testicles, abdominal area
- Sharp, sudden, severe pain
- Hematuria
- Dysuria
- Urinary frequency
Diagnosis:
-Ultrasound, CT scan
-IVP
-Renal Stone Analysis
-Retrograde pyelogram
-Cystoscopy
-Measure urine pH
Risk Factors -Etiology:
-Infection
-Urinary stasis & retention
-Immobility
-Dehydration
-Increased uric acid
-Increased urinary oxalate
-Family history
Renal Calculi
What does post-op care include for patients after removal of stones?
- Monitor for bleeding
- Prevent infection
- Accurate I&O
- Encourage fluids
- Pain medications & spasmolytics
What percentage of ICU patients will develop AKI?
60%
What are some causes of prerenal AKI?
Sepsis, hypertension, perfusion disruption
What are some causes of intrarenal AKI?
Nephrotoxic medications (NSAIDs), acute tubular necrosis (ATN), blood clots within the kidneys
What are some causes of postrenal AKI?
Stones, tumors, BPH
Phase of AKI:
-Common triggering events: significant blood loss, burns, fluid loss, diabetes insipidus
-Renal blood flow is normal
-Tissue oxygenation 25% of normal
-Urine output below 0.5 mL/kg/hour
Duration: hours to days
Onset phase
Phase of AKI:
-Urine output below 400 mL/day, possibly as low as 100 mL/day
-Increases in BUN and creatinine levels
-Electrolyte disturbances - acidosis, and fluid overload (from kidneys inability to excrete water)
Duration: 8 to 14 days or longer, depending on nature of AKI and dialysis initiation
Important to watch for hyperkalemia during this phase due to the GFR being decreased, meaning protein isn’t broken down and potassium is then high
Oliguric (anuric) phase
Phase of AKI:
-Occurs when cause of AKI is corrected
-Renal tubule scarring and edema
-Increased GFR
-Daily urine output above 400 mL
-Possible electrolyte depletion from excretion of more water and osmotic effects of BUN
Duration: 7 to 14 days
Watch for fluid and electrolyte loss
Diuretic phase
Phase of AKI:
-Decreased edema
-Normalization of fluid and electrolyte balance
-Return of normal
Duration: Several months to 1 year
Recovery phase
What are the symptoms of acute kidney injury?
-Raised Urea, Creatinine and Uric Acid
(Confusion, drowsiness)
-Failure to excrete normal acidic products (metabolic acidosis, respiratory hyperventilation)
-Electrolyte imbalances (hyperkalemia and dysrhythmias)
Why does nausea and vomiting occur with kidney failure?
Due to fluid retention (hypervolemia)
Why does confusion occur in those with AKI?
When excess fluid dilutes the sodium in the body, sodium doesn’t reach the brain and causes confusion
What medication is given for patients with AKI to prevent hyperkalemia?
Kayexalate
What medical management is needed for patients with AKI?
- Fluids and diuretics given simultaneously for fluid balance
- Kayexalate (pulls potassium out through the bowels)
- Renvela (phosphate binder; used to treat high levels of phosphate by binding to free phosphate in the blood. The kidneys can’t excrete phosphate)
- Sodium bicarbonate to treat metabolic acidosis
What are some nursing considerations for a patient with AKI?
- Education on NSAIDs (avoiding nephrotoxic drugs)
- Daily weight
- Proper hydration, I/O
- Diet education (manage sodium intake, low potassium and phosphorus foods)
What are the acute indications for dialysis?
** Remember AEIOU **
- Acidosis (pH < 7.1)
- Electrolytes (Refractory Hyperkalemia)
- Intoxication/Ingestions (Toxic Alcohols, Salicylates, Lithium)
- Overload (CHF)
- Uremia (Uremic pericarditis, uremic encephalopathy)
- Surgeon connects artery to piece of soft tubing that acts as a vein
- It’s placed under the skin of your upper or lower arm
- Indicated for hemodialysis
AV Graft
- Best choice for hemodialysis
- Made by connecting an artery to a vein
- Optimal blood flow
- Lowest chance of infection
AV Fistula
What are some complications of hemodialysis?
- SOA between treatments
- Hypotension
- Muscle cramps (removal of potassium)
- Hemorrhage (access sites are vascular)
- Dysrhythmias (electrolyte imbalance)
- Air embolism
- Dialysis disequilibrium (change in mental status due to fluid shifts)
Which type of renal therapy is important for patients with hypotension?
Patients are clinical unstable
Continuous renal replacement therapy (CRRT)
What is HLA?
Human leukocyte antigen
Matching of HLA means the tissue and blood match
What is a good indicator that the kidney transplant was a success?
Urine output increases immediately
Post Kidney Transplant Rejection Signs
- Onset within 48 hours
- Malaise, high fever
- Graft tenderness
- Organ must be removed to decrease sign and symptoms
- Antibodies attaching the foreign body organ
Hyperacute
Post Kidney Transplant Rejection Signs
- 1 week to 2 years
- Oliguria, anuria
- Increased temperature
- Increased BP (fluid retention)
- Flank tenderness
- Lethargy
- Increased BUN, K, Creatinine
- Fluid retention
Acute
Post Kidney Transplant Rejection Signs
- Gradual over months to years
- Increased BUN, Creatinine
- Imbalances in proteinuria; electrolytes
- Fatigue
Chronic
Antidiuretic hormone (ADH) acts within the kidney to promote reabsorption of _______
water
Which lab value most accurately reflects possible renal dysfunction?
a. BUN of 15 mg/dL
b. Creatinine of 5.0 mg/dL
c. Urine specific gravity of 1.020
d. BUN to creatinine ratio 10:1
b. Creatinine of 5.0 mg/dL
These electrolytes have an inverse relationship in patients with AKI
Calcium and phosphorus
When blood phosphorus concentration increases in AKI, calcium acts as a compensatory mechanism for the elevated phosphorus and is lower. Calcium can be low due to decreased absorption from the intestines
Which electrolyte imbalance is associated with AKI?
Hyperkalemia
Burn Depth
- Painful
- Does not blister
- Does not scar
- Only the surface of the epidermis is affected
Superficial thickness (first degree)
Burn Depth
- Blisters and weeps
- Increased risk of infection and scaring
Partial or intermediate thickness (second degree)
Burn Depth
- Dry
- Insensate to light touch and pin prick
- Small areas will heal with substantial scar or contracture
- Large areas require skin grafting
- High risk of infection
- Involves all layers of the skin
Full thickness (third degree)
Burn Depth
- Involves muscle or bone
- Leads to loss of the burned part
Fourth degree
Phases of Burn Care
Duration: from onset of injury to completion of fluid resuscitation
Priorities: First aid, prevention of shock, prevention of respiratory distress
Emergent/Resuscitative
Phases of Burn Care
Duration: from beginning of diuresis to near completion of wound closure
Priorities: wound assessment and initial care, wound care and closure, and prevention of infection
Acute/Intermediate
Phases of Burn Care
Duration: from major wound closure to return to individuals optimal level of physical and psychosocial adjustment
Priorities: prevention of scars and contractures; physical, occupational and vocational rehabilitation; Functional and cosmetic reconstruction; psychosocial counseling
Rehabilitation
What are the ABCDE of assessments during the emergent phase?
Airway
Breathing
Circulation (focus on fluid status for HR and edema)
Disability (LOC)
Environment (needs to be a clean environment to avoid infection; warm)
Which physiologic changes occur during the emergent phase for burn patients?
- Hemoconcentration & Hypovolemia: results from capillary leak from intravascular to interstitial space leading to edema formation. Hematocrit and RBCs increase
- Hyperkalemia: results from massive cell destruction immediately after burn injury
- Hyponatremia: water shifts from the interstitial to the vascular space. Large amounts of Na+ is lost in trapped edema fluid and exudate and by shift into cells as K+ is released from cells
What management is completed during the emergent phase with burn patients?
- Establish airway & supply oxygen
- Large-bore IV catheter (fluid replacement with LR - most similar to plasma)
- Cover wound with clean, dry cloth/gauze
- Maintain warm environment
- Indwelling catheter
- NGT insertion
What causes the red color seen in a UA after a burn injury?
Increased secretion of myoglobin
Incision made in the burn to restore tissue perfusion and reduce edema
Escharotomy/Fasciotomy
What are the treatments used during the Acute/Intermediate phase for burn patients?
- Administration of Protonix (proton pump inhibitor) - decreases stomach acid production and used to reduced gastric motility; burn pts are at risk of developing stomach ulcers
- Antibiotics
- PCA pump
- Nutritional support (high protein, high calorie)
- TPN
What is GIFT for organ transplants?
G - GCS less than or equal to 5
I - Injured brain or critical lung condition
F - family mentions donation
T - Talk of transition to comfort measures/hospice considered
Which electrolyte imbalances are often present in patients with burn injuries?
Immediately after burn injury, hyperkalemia may result from massive cell destruction.
Hypokalemia may occur later with fluid shifts and inadequate potassium replacement.
Hyponatremia may be present from plasma loss or may occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space
How is the immune system affected in patients with burn injuries?
The skin, which is the largest barrier to infection, exposes the patient to the environment after a burn injury.
Cytokines and other substances cause leukocyte and endothelial cell dysfunction.
Systemic nervous system releases norepinephrine and epinephrine
Graft Rejection
- Causes thrombosis and occlusion of graft vessel
- Usually occurs due to blood type mismatch
- Occurs immediately
- Organ must be removed immediately
Hyperacute rejection
Graft Rejection
- Can often be treated
- Most common type of rejection
- Occurs between weeks-months after transplant
- Causes leukocyte infiltration to graft vessel
Acute graft rejection
Graft Rejection
- Results in thickening and fibrosis of graft vessel
- Occurs months-year after transplant
Chronic rejection
Which cells are undifferentiated?
Stem cells
Type of lymphoma that is commonly found in the neck, underarms, or chest
** most curable **
Hodgkin Lymphoma
Type of lymphoma that arises in lymph nodes throughout the body
Non-Hodgkin Lymphoma
What are the signs and symptoms of lymphoma?
- Lymph node enlargement
- Cough
- Liver enlargement
- Nephrotic syndrome
- Night sweats
- Itchy skin
- Spleen enlargement
- Bone marrow involvement
What are the signs and symptoms of leukemia?
- Petechiae (due to low platelets)
- Bones become tender
- Anemia (fatigue)
- Bleeding tendency or hemorrhagic tendency
- Swollen lymph nodes
- Enlarged spleen, kidney, and the liver
- Pain in joints and bones
- Loss of weight
What is the highest priority for those with leukemia?
Infection (high levels of dysfunctional WBCs) and bleeding
How is leukemia diagnosed?
Bone marrow biopsy
What are the labs usually seen with leukemia?
- Low platelets
- Low hemoglobin/hematocrit
- Low neutrophils
- High blast cells
** with low platelets, need to look at PT and INR to see how long it takes for the blood to clot **
Treatment for Leukemia
Goal: achieve rapid, complete remission
Neutropenia + adverse side effects
** WBCs should be 0 **
Induction Therapy
Treatment for Leukemia
Goal: Cure
Performed early in remission
Consolidation Therapy
Treatment for Leukemia
Goal: Prevent relapse
2-3 years long
Maintenance Therapy
At which level of chemo treatment is stem cell transplant considered?
After induction therapy
How long do patients need to wait after chemotherapy before receiving bone marrow transplant?
2 to 3 days
What kind of management is delivered for patients after bone marrow transplant?
- TPN
- Nausea and pain management
- Fluid and electrolyte management
- Blood product support
- Antibiotics
- GVHD prophylaxis
Transplant Complications
- Body doesn’t take the stem cells
- Patient will need another infusion due to not having an immune system
Graft vs. Host Disease (GVHD)
Transplant Complications
- Occurs in the liver; artery becomes clotted off
- S/S: jaundice, ascites, symptoms of liver dysfunction or failure
- No good treatment; just supportive care
Sinusoidal Obstructive Syndrome (SOS)
Stages of HIV
Flu-like symptoms that occur within first 2-4 weeks of contracting HIV infection
Acute infection
Stages of HIV
Chronic HIV infection after acute infection stage, can last for decades
Clinical latency
Stages of HIV
Occurs when CD4 cell count falls below 200 cells/mm3, and vulnerable to opportunistic infections
AIDS
During which stage can a person infected with HIV transmit the virus?
At any stage
Which tests are used for HIV?
- ELISA (first line testing, not the most accurate)
- Western Blot (used to confirm HIV once ELISA is positive)
- CD4 and viral load (CD4 and viral load work opposite of each other. We want CD4 levels high and viral load levels low)
Cancer of the blood vessels that cause development of small, reddish-purple, non-painful bumps on the skin
Kaposi’s Sarcoma
What are the different HAART medication classes?
- CCRS Antagonist
- Fusion Inhibitors
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Integrase inhibitors
- Protease Inhibitors (PIs)
What are the nursing considerations for patients with HIV?
- Monitor for opportunistic infections
- Cluster care to prevent fatigue
- Neutropenic precautions
- Nutrition
- Psychosocial support
- Discharge education
