week 1 Flashcards
1
Q
kidney infection signs and symptoms
A
- delirium
- flu-like
- LBP
2
Q
functions of the renal system
A
- filters waste products from metabolism (ammonia, drugs) - along with liver
- regulates ion levels in plasm - K+ goes up with kidney issues
- regulates blood pH - produces bicarb
- conserves valuable nutrients - reabsorbs glucose
- regulates blood volume - water balance
- regulates RBC production - produces erythropoietin
3
Q
kidneys make up _ body mass but receives _ % of cardiac output
A
- 1% of body mass
- 25% of cardiac output
kidneys have increased metabolic rate and so need increased O2 to maintain function
1.2-1.3 L/min in adult
4
Q
anatomy of kidneys
A
- paired, retroperitoneal: nearby structures inflamed with inflamed kidneys (LBP)
- right lower than left
- bean-shaped
- concave surface - renal hilum, contains entry/exit of renal a/v and ureter
- divided into outer cortex and inner medulla
5
Q
renal cortex
A
- outer portion of kidney
- contains glomeruli and proximal/distal tubules
- 75% of renal parenchyma is cortex
6
Q
renal medulla
A
- inner portion of kidney
- cone-shaped - cones KA “renal pyramids”
- 8-18 pyramids per kidney
- contain Loops of Henle and collecting ducts
- medullary pyramids narrow to renal papilla to emtpy urin/filtrate -> minor calyx -> major calyx -> renal pelvis -> ureter
7
Q
functional unit of kidney is
A
nephron
* glomeruli and loop of henle
* each kidney has 1 million nephrons
* located in both cortex and medullary areas
8
Q
glomerulus - tuft of capillaries
A
- filters H2O, K+, sugar, salt -> everything but RBC
- filtrate enters nephron, urine building block
- surrounded by capillary network: exchange, ion/H2O/pH balance
9
Q
_ % of filatrate automatically reabsorbed at proximal convoluted tubule
A
90%
* 10% to Loop of Henle: fine-tuning, reabsorb/conserve based on blood values, specizlied cells for transport (can be impacted by diuretics)
10
Q
functions of nephron
A
- filtration: blood filtered in glomerulus -> tubule
- tubular reabsorption: solutes and H2O from lumen into peritubular capillaries and returned to circulation
- tubular secretion: filtrate in tubule further modified by secretion of substances (urea, meds) from peritubular capillaries into lumen
- urinary excretion: filtrate/urine is transported to bladder
11
Q
normal urine output is _ with normal intake of _
A
- output is 800-2,000 mL/day
- intake is 2 L/day
euvolumia
12
Q
different urine colors
A
- normal: pale yellow
- darker: more concentrated, dehydrated
- pink to dark red: hematuria (RBC) in urine
- cloudy: infection or WBC
- rust: rabdo
- also
- polyuria: > 3L/day urine production, more dilute, in DM, decreased total blood volume
- urinary frequency: urinate many times but normal or less than normal volume
- nocturia: excessive urination at night
- oligaria: daily urine output < 400 mL, indicative of increased mortality
- anuria: no urine, ominous finding
13
Q
prerenal causes of acute renal failure
A
- heart failure
- lack of perfusion
- shock/sepsis
- hemorrhage
- hypovolemia
- excess vomiting, diarrhea
- diuretics
- conditions that decrease renal blood flow (RBF)
55%
14
Q
intrinsic/intra-renal causes of acute renal failure
A
- kidney disease secondary to DM
- high BP
- kidney stones
- interstitial nephritis, acute glomerulitis, tubular necrosis, ischemia, toxins
- injury/inflammation of kidneys
40%
15
Q
post-renal causes of acute renal
A
- kidney stones in ureter
- blood clot
- bladder cancer
- prostate/cervical cancer
- conditions that obstruct urine outflow
5-15%
16
Q
acute kidney injury (AKI)
A
- severe UTI
- infection
- pyelonephritis: when a UTI goes to kidney and ureters
- S&S: back pain, fever, chills, malaise, N/V, confusion, hematuria, painful urination
do Murphy’s percussion
17
Q
intra/post renal caliculi/stones
A
- increased [] of salts in blood: calcium salts, uric acid
- UTI
- urinary tract obstruction
- S&S: N/V, renal/colic pain, hematuria
- treatment: manage pain, hydration, cystoscope (snare and remove), lithotripsy (ultrasound)
18
Q
rhabdomyolysis
A
- breakdown of muscle fibers (sarcolemma): results in myoglobin release and waste into blood stream
- myoglobin can cause AKI and ultimately renal failure
19
Q
signs and symptoms of rhabdo
A
- triad: muscle pain, weakness, dark urine
- compartment syndrome due to inflammation and fluid shifts
- AKI: increased myoglobin forms casts in nephron, iron degradation causes increase ROS
- decreased urine output, reddish brown urine
20
Q
rhabdo lab results
A
- creatine kinase >5x ULN (normal is 60-174, 1500-100,000)
- increased CK increases risk of AKI and kidney damage
- hypovolemia due to ECF influx to muscles
- hyperkalemia and hyperphosphatemia due to damaged muscle cells
- hypocalcemia due to influx to injured muscles
- metabolic acidosis due to kidney injury
21
Q
causes of chronic renal failure (CRF)
A
- diabetic neuropathy (>30%)
- hypertension (20-25%)
- glomerulonephritis (10%)
- polycystic kidney disease (5%)
- kidney infections, obstructions, renal vascular disease
22
Q
stages of CKD
A
- higher GFR is healthier kidney
- early disease is “silent” but still damaging
23
Q
assessment of renal function
A
- glomerular filtration rate (GFR)
- albumin
- creatinine
24
Q
GFR for renal function
A
- flow rate of filtered blood through kidney over time
- gives rough measure of number of functioning nephrons
- difficult to measure: requires 24 hour urine collection and special dyes
25
albumin for renal function
* albumin is protein made my liver, found in blood and not in urine
* normal albumin in urine is zero?
* more than 30 mg/g is albuminuria/proteinuria
26
creatinine for kidney function
* not filtered if kidney is damaged
* filtered in glomerulus and excreted by kidney (not reabsorbed)
* as plasma C increases, GFR exponentially decreases
* increased creatine in blood is decreased kidney function
| most common test
27
potassium (K+) in renal dysfunction
* hyperkalemia
* muscle weakness, flaccid paralysis, paresthesias, ECG, widening of QRS progressing to ventricular tachycardia/fibrillation, cardiac arrest
28
calcium is renal dysfunction
* hypercalcemia
* stones (renal/biliary)
* bones (pain)
* groans (abdominal pain)
* thrones (polyuria)
* N/V, fatigue, ECG changes short QT interval
29
bicarbonate in renal dysfunction
* metabolic acidosis (decreased HCO-3)
* lethargy, fatigue, muscle weakness, decreased cardiac contractility, decreased cardiac output, dysrhythmias
30
peritoneal dialysis (PD)
* uses peritoneum as semipermeable membrane and dialysate infused directly into abdomen
* peritoneam highly vascularized: allows waste products and fluids to pass from blood to dialysis solution
* dialysate infused into abdomen and allowed to remain for several hours prior to drainage
* PT during infusion/removal
31
hemodialysis (HD)
* attempts to perform normal kidney function by passing blood through semi-permeable membrane (dialyzer) allowing metabolic waste products to diffuse into a correction fluid (dialysate) - individual for patient
* promotes correction of fluid and electrolyte abnormalities, toxic material removal, maintenance of acid-base balance
* accomplished through vascular access that allows high flows and repeated cannulation while minimizing infection and clot formation
| 1 L/hr
32
types of HD access
* **temporary access**: tuneled catheter
* in central vein (internal jugular), least durable
* **AV fistula**: has "thrill"
* surgeon constructs access by combining A and V
* 3-6 months to mature but very durable
* **AV graft**: man-made tube (gortex) inserted by surgeon to connect A and V
* 2-6 weeks to mature, less durable than AV fistula
* no BP measurement on arm with fistula
* protect arm from injury
* control hemorrhage: bleeding is arterial, maintain direct pressure
* thrill is normal
33
continuous renal replacement therapy (CRRT)
| 24/7 dialysis in ICU
* if worried for CV status, low and slow - patients usually critically ill (hemodynamic status concern)
* use extracorporeal blood circuit through small-volume, low-resistance filter
* provider. continuous removal of solutes and fluid
* PT may be contraindicated
| 100 mL/day
34
implications of dialysis
* mobilization activities are typically contraindiciated during HD and during inflow/outflow of dialysate with PD
* CRRT may be an exception but need to know "hemodynamic stability"
* assess fluid and electrolyte status
* expect potential dehydration/hypovolemia, hypotension, and patient complaints of fatigue after
* PD: dialysate in abdomen may cause SOB/DOE
* mointor vitals closely
35
functions of GI tract
* **digestion**: physical breakdown, chemical alteration of food stuff to allow absorption along GI tract
* involves GI motility, pH changes, biological detergents, enzymes
* **absorption**: directed movement of nutrients across intestinal lining
* **excretion**: food residue, hyrdophobic molecules (drugs, bacteria, dead cells)
* **host defense**: largest lymphoid organ in body with extensive surface area
* gut microbiome, implications in health
36
esophagus
* fibromuscular tube connecting throat/pharynx with the stomach (25 cm, < 1 in diameter)
* food passes by peristaltic contractions
* sphincters: bundles of muscle that control entry/exit (upper esophageal spincter - swallowing, lower - to stomach)
| GERD
37
gastroesophageal reflux disease
| GERD
* reflux of gastric contents (acid, pepsin, bile) into esophagus
* **contributing factors**:
* incompetent lower esophageal sphincter (LES)
* impaired gastric emptying through pyloric sphincter to duodenum
* hiatal hernia
* alcohol abuse
* more common in children with developmental delays
* common in DM: CN X (vagus) damage
38
complications of GERD
* regurgitation/malnutrition
* esophagitis
* Barrett's esophagus: pre-cursor to esophageal canacer (transformation of normal esophageal squamous epithelium to columnar epithelium) - pre malignant, increase risk for developing esophageal cancer
* respiratory compromise, associated with asthma and COPD
39
stomach
* **reservoir function**: controlled release of chume into SI, stomach can expand to hold 2-4 L of fluid/food
* **mechanical digestion**: gastric motility (peristalsis)
* **chemical digestion**: digestive enzymes continue digestion of protein (pepsin), fats (lipase) --> lots of cells secrete mucus lining, protect against HCl
* **hydrochloric acid**: chemical digestion, activates some digestive enzymes (pepsin), immune defence (kills bacteria)
* **intrinsic factor (IF) protein**: bind vitamin B12 for absorption in SI (ileum) --> dysfunction is pernicious anemia
| PUD, GIB
40
gastric defense/mucosal defense
* protective barrier/function
* compact epithelial cell lining
* mucus covering
* bicarbonate ions (HCO-3): buffers H+
* blood flow
41
gastritis and peptic ulcer disease (PUD)
* **gastritis**: inflammation of inner lining of stomach (mucosa)
* acute: excessive acid production > gastric defense (NSAIDS, ASA, ETOH)
* stress induced: common in critical illness, especially patients with mechanical ventilation
* **peptic ulcer disease**: increased acid secretions and digestive enzymes erode digestive mucosa, H. pylori infection (>70%)
* complications: hermorrhage, perforation peritonitis, scarring
* defined by site of origin: gastric, duodenal, esophageal
42
gastrointestinal bleeding (GIB)
* check lab values: hemoglobin, hematocrit
* 75% GI bleeding in upper tract: esophagus, stomach, small bowel
* 20-25% in lower tract: terminal ileum, colon, rectum
* 50% due to NSAID use: eldery, female
* continued bleeding and re-bleeding are high predictors of mortality and morbidity in older patients
43
GIB red flags
* **red flags**: suggest shock
* syncope, hypotension, pallow, diaphoresis, tachycardia
* fatigue, weakness, SOB, abdominal discomfort
* decrease in H/H
* vomiting of blood (hematemesis): coffee ground emesis usually from upper GI bleed
* black tarry stool (melena): can be U/LGIB
44
NSAIDs
* acetylsalicylic acid (ASA, aspirin, Bayer, Ecotrin)
* traditional NSAIDs (ibuprofen, naproxen)
* COX 2 inhibitors (Celebrex Viox)
45
NSAIDs and GIB
* 15% of long-term NSAIDs users develop PUD
* ASA and traditionals block COX 1 and COX2: pain relief with increased GIB risk
* celebrex and Vioxx are selective for COX 2 only: pain relef with decreased GIB risk but increase CVA/MI risk
* COX 1 facilitates clotting
* COX 1/COX 2 facilitate pain
* blocking Cox 2 increases Cox 1 activity --> increased clotting, CVA/MI
46
small intestine
| absorbs nutrients
* starts at pylorus and ends at ileocecal junction
* 3 regions (proximal to distal): duodenum, jejunum, ileum
* functions: mixes/grinds (segmentation) and propels (peristalsis) contents - coordinated, enteric NS
* digests and absorbs nutrients
* secrete regulatory hormones
47
SI function
* **chemical digestion**:
* endocrine (hormone) cells and exocrine (digestive enzymes) function
* food -> duodenum (endocrine) -> pancreas (exocrine)
* hormones regulate gastric, pancreatic, and gall bladder function
* chyme enters duodenum and releases cholescystokinin (CCK) that increases pancreatic enzyme and bile release
* **absorption**:
* villi and micromilli: increase intestinal absorptives - absorption of nutrients
* lacteals (lymphatic capillaries) for fat absorption (chyle)
48
large intestine
| water balance
* **function**
* final stage of digestion through bacterial action: ferment carbs, produce B vitamines, vitamin K
* mucus is major secretion: no enzyme secretion
* main role of colon is re-absoprtion of water with ions and vitamins: epithelial cells reabsorb salts, water flows by osmosis
| CD, UC, IBS, celiac, acute, CA
49
crohn's disease and ulcerative colitis
* **CD**: patchy inflammation that may occur anywhere along digestive tract (entire bowel wall)
* pain is commonly experienced in right lower abdomen
* **UC**: inflmmation continuous throughout affected LI/colon
* innermost lining/mucosa
* pain is common in lower left abdomen
* **common presentation**
* abdominal cramping/pain, diarrhea, obstruction, fatigue, malabsorption (weight loss/malnutrition)
* joint pain, anemia
* **medical management**
* immunosuppressants: azathioprine
* biologics: infliximab, adalimumab (TNF alpha R blocker)
* anti-inflammatory agents: steroids
* **surgery**: surgical resection of bowel, especially in Crohn's
50
irritable bowel syndrome (IBS)
* disturbed bowel function *without* structural abnormalities
* spasmodic motility pattern
* malabsorption
* nutrition deficiency and loose stools
* etiology unknown but believed to be related to Colonic sensitivity
* diagnosis of exclusion: exclude UC, CD, diverticulosis
51
Celiac disease
* autoimmune disorder that occurs in genetically predisposed
* ingestion of gluten leads to SI damage
* leads to malabsorption and symptoms of bloating, diarrhea, gas, fatigue
* other issues: anemia (decreased absoprtion of Fe, B12), osteoporosis (decrease absorbed Ca, vD)
52
hernia
* protrusion of organ through wall of cavity that normally contains it
* hiatal: gastro-esophageal junction moves above diaphragm with some stomach
* ventral: incision-related hernia where abdomen contents protrude throug linea alba
* inguinal: protrusion of abdominal cavity through inguinal canal
53
acute abdomen
* KA peritonitis
* sudden, sever abdominal pain < 24 hours
* often a medical emergency
* causes: appendicits, cholecystitis, pancreatitis, ischemic bowel, AAA
* physical exam: identify location, palpation reveals rigidity/rebound tenderness, bowel sounds diminished/absent
54
colorectal cancers
* progression often starts with benign polyp (early detection in colonoscopy)
* symptoms: bleeding, pressure/pain with defecation, change in elimination
* associated with age, family history, diet, exercise, UC/CD
* 3rd most common CA and 3rd leading cause of death
55
ileectomy
resection of SI
56
colectomy
resection of large intestine
57
ostomy
surgically created opening in body for discharge of body wastes
| ileostomy: SI
colostomy: large bowel
58
stoma
end of SI or LI that is protruding through abdominal wall
59
benefits of bariatric surgical procedures
* weight loss
* remission of T2 diabetes
* improvement in CV risk factors and CV health: improved lipid profiles, decreased BP or HTN
* improvements in mental health: decreased depression
* better sleep: decreased obstructive sleep apnea
* decreased hip and knee pain
* improved fertility
60
additional considerations for bariatric surgical procedures - GI disorders
* absorptive disorders (IBS, UC, Crohn's)
* nutrition deficiencies - malnutrition
* post-op pulmonary complications: increased risk with upper > lower abdominal surgery
61
common post-op complications (POC) with bariatric surgery
* pain, bleeding, infection, post-surgery adhesions
* pulmonary complication: atelectasis, desat, PNE, PE, respiratory failure
* ileus: partial, paroxysmal - decreased motility, paraylsis of bowel, leads to constipation/discomfort/NV
* bowel leakage: sepsis
62
medications for GI
* antacids: drugs that decrease acid secretion by gastric parietal cells
* proton pump inhibitors: prilosec, nexium, prevacil
* H2 receptor blockers: pepcid
63
pancreas
* endocrine and exocrine function
* endocrine: islets of Langerhands - hormones, insulin, glucagon
* exocrine: duct cells secrete NaHCO3, acinar cells secrete digestive enzymes -> exocrine portion of pancreas are acinar and ducts
64
pacreatitis
* **inflammation of pancreas**
* acute: NV, fever
* chronic: low flying, masks as MSK/LBP
* **pancreatic enzymes** (especially trypsin) activated in pancreas instead in SI -- leads to inflammation and autodigestion
* 80,000 cases per year: 90% from alcohol abuse or gall stones
* severe abdominal/epigastric pain - radiates to back, NV, worse after fatty foods, relieved with forward leaning
* dehydration --> hypotension
* severe pain leads to HTN and tachycardia
65
pancreatic insufficiency and cystic fibrosis
* enzyme synthesis and secretion normal
* inability to secrete bicarb and water: limits amount of enzymes released to intestinal lumen
* if they reach lumen, often inactive: not enough alkaline to neutralize gastric acid
* treatment: enzyme supplements and antacids
66
liver anatomy
* consists of 2 main lobes, both made of 8 segments: each segment made of thousands of lobules
* circulation includes: hepatic a (20-40%) - O2 enriched blood, portal v (60-80%) nutrient enriched blood, hepatic v
* in RUQ
* percussion dullness in mid clavicular line used to determine liver span
* upper border: 5-7th intercostal space
* lower border: usually ends at costal border
67
liver functions
* **excretory**: production of bile for digestion of fats
* **sympathetic**: produces plasma proteins (albumin) and coagulation factors, synthesizes triglycerides/cholesterol/carbs
* **metabolism**: storage site for glycogen/gluconeogensis (glucose storage), protein catabolism and synthesis of urea, breaks down RBCs and remove excess bilirubin
* **detoxification**: detoxifies noxious compounds found in chemicals (ETOH) and drugs (first pass effects)
68
with liver problems
* decreased albumin production/in blood --> decreased water reabsorption
* fluid in blood slowly decreases
* look swollen (ascites) --> BUT patient is hypovasculate (low BP)
* do not use diuretics to get rid of fluid
69
S&S of hepatic dysfunction
* **jaundice**: excessive deposition of bile pigments (hyperbilirubinemia, >1.3 mg/dL)
* **ascites**: abdominal swelling/fluid in peritoneum, leakage from portal v system
* due to portal HTN and/or hypoalbuminemia
* develops due to: altered starling forces in portal vv (low oncotic pressure due to hypoalbuminemia), with increased portal venous pressure
* medical interventions: diuresis and Na restriction, paracentesis (fluid removal from abdominal cavity)
70
hepatic disorders -- pulmonary complications
* ascites can impact diaphragm and lung volumes: fluid volume elevates diaphragm --> decreased lung volume, rapid/shallow breathing, looks like restrictive lung pathology
* hepatopulmonary syndrome: watch out or O2 desat
71
varices
* portal HTN causes congestion in spleen, stomach, esophagus
* collateral vessels develop which become distneded and varicose (stomach and esophagus)
* varices may burst, leading to upper GI bleeding/hematemesi
72
hepatic encephalopathy
* reversible decrease in neurologic function due to shunting of blood awy from portal circulation
* associated with hepatic failure resulting in accumuluation of noxious metabolic by-products, most commonly associated with increased serum ammonia
* S&S: asterixis (liver flap) - alternating flexion/extension of hands when patient asked to extend wrist with arms extended
73
aneurysm
ballooning and weakening of vessel wall
74
dissection
tear in intimal layer
75
presentation of ruptured/dissection AAA
| abdominal aortic aneurysm
* sudden abdominal/back pain - tearing sensation
* hypotension and tachycardia: sweating, clamminess, dizziness
* NV
* pulsatile mass in abdomen (obscured by obesity) - if < 5 cm, not detected usually
| hypoTN: losing blood into walls of aorta - eventually everything bursts
76
aneurysm risk factors/complications
* RF: age, family history, HTN, high cholesterol, CAD/atherosclerosis, smoking, male
* complciations: thrombosis, distal emoblization, dissection and rupture
| do not go over 90 bpm, 150 systolic
