NCAF Exam 4 Review - nursing care of adults and family PDF

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nursing care of adults and family...

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•Know normal ranges for: BUN serum creatinine, Serum Sodium Serum Potassium •Understand glomerular filtration rate •Is protein in the urine normal-page 1314 last paragraph •What may cause increased protein in urine •How to collect a 24 hour urine specimen •How to collect a urine culture •What is a renal threshold for glucose and what is the number value- see page 130

•What drugs are extremely harmful to the kidney

•Make sure patient understands to complete antibiotic regimen in the treatment of pyelonephritis

•Be familiar with corticosteroids and cytotoxic drugs to suppress immunity

•Meds for ____________ may need to be used in patients with glomerulonephritis or nephrotic syndrome

•ACEis can decrease ______________ in the urine •Heparin may reduce ________________________ and improve kidney function •Traditional chemotherapy has limited effect on renal carcinoma, what other drugs are used instead?

•Be familiar with fluid restoration and measures for bleeding used in kidney trauma •What is the best indicator of fluid gain? •In general adult urine output expectations are ____________mL/kg/hr •1 Liter of fluid is equal to _____ kg

REASONS FOR A FOLEY: Foleys are not kept in patients just because they are incontinent •Acute urinary retention or obstruction •Accurate measurement of urine in critically ill patients- urometer •Perioperative use in selected surgeries •Assistance with healing of stage III or IV perineal and sacral wounds in incontinent patients •Hospice/comfort/palliative care •Required immobilization for trauma or surgery •Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures). KIDNEYS •Kidneys maintain __________________ balance, & create urine for elimination of wastes • Hormonal Functions- Help adjust ____________________, Control Red blood cells by Producing ________________________ for red blood cell synthesis, Convert vitamin D to an active form •Regulatory Functions-The kidney controls ___________________ balance •The kidney processes that maintain fluid, electrolyte, & acid base balance are _____________________, _________________________, _______________________ •These processes use _______________, _________________, ___________________ •When systolic BP drops below _____mm/Hg GFR stops- adequate BP is very important for renal function •Normal urine output is up to _______L/day •Renal threshold for glucose is ______ mg/dL. •The __________ is the functional unit of the kidney •There are about ________________ nephrons per kidney •Each nephron is capable of forming __________ by filtering waste products & water from the blood •The glomerulus is inside the ______________ •____________________________ is the first process in urine formation-the normal GFR is 125 mL/hr and most adults should at least be above 90 .... •Glomerular filtrate: Water, electrolytes, & other small particles (creatinine, urea nitrogen, glucose ) are filtered across the glomerular membrane into the _______________ capsule to form glomerular filtrate

PYELONEPHRITIS ACUTE PYELONEPHRITIS •ACUTE ______________________________in kidney and renal pelvis (upper urinary tract) from bacterial infection with or without reflux or obstruction •Reflux is the _______________or__________________ of urine to the renal pelvis and kidney. •Acute tissue inflammation, local edema and tubular cell necrosis •Causative organisms - Mainly E. Coli and Enterococcus faecalis –both _____________ organisms •In __________ patients- Proteus mirabilis, Klebsiella species and Pseudomonas aeruginosa •When the infection is ___________________, Staph Aureus, Candida, and Salmonella

•_______________ may develop (pockets of infection that can occur anywhere in the kidney.) CHRONIC PYELONEPHRITIS •Results from repeated or continued upper ________ that occur almost exclusively in patients who have anatomic abnormalities, congenital structural abnormalities, neurogenic bladder, urinary stasis (bedrest, paralysis), reflux or obstruction •_____________________and scar tissue can develop from chronic inflammation •Most Common in ______________ who are young and sexually active •Chronic-less dramatic presentation but similar symptoms to acute •Older adult-Can lead to acute _________________ (assess older adult who has new onset for signs of urinary/renal infection)...leading to __________________**** LABS •Urinalysis –what result is indicative of infection?? •UA usually obtained by clean catch...How do you get a clean catch specimen for a urine culture??? •Baseline kidney function -BUN and creatinine, GFR- Blood cultures, WBC count IMAGING •KUB (what does KUB stand for?) •CT •Other diagnostic assessment •Renal scan, Kidney biopsy •Testing antibody coated bacteria in urine-for enzymes (eg. lactate dehydrogenase iso enzyme 5)-present with kidney deterioration TREATMENT •Nonsurgical medical management- (_________________________ preferred over NSAIDs) •_________________ to treat infection will help decrease pain •In patients with long-term catheter- The _________________ needs replaced before starting antibiotics...because catheter will be covered with a biofilm of concentrated organisms.... •___________________ antibiotic is not recommended for patients with difficulty voiding or catheters} it does not limit recurrence or severity of UTI GLOMERULAR DISEASES •Glomerular damage is commonly caused by ____________-____________ processes, which often lead to glomerulonephritis. Non-inflammatory causes, such as metabolic disease (diabetes, amyloidosis) can also result in significant damage to the glomeruli •The pathophysiology of glomerular diseases is complex; most patients present with either chronic glomerulonephritis (Nephritic syndrome), low level proteinuria, microhematuria, oliguria and hypertension •_______________ syndrome- high level proteinuria and generalized edema •All glomerular diseases can progress to acute or chronic renal failure •Thus, quick ___________ and immediate initiation of _______________ are required to prevent irreversible kidney damage

COMPLICATIONS OF GLOMERULONEPHRITIS •Glomerulonephritis can damage your kidneys so that they lose their _____________ ability. As a result, dangerous levels of fluid, electrolytes and waste build up in your body. •____________________________. Loss of function in the filtering part of the nephron can result in rapid accumulation of waste products. You might need emergency dialysis — an artificial means of removing extra fluids and waste from your blood — typically by an artificial kidney machine. •____________________________. Your kidneys gradually lose their filtering ability. Kidney function that deteriorates to less than 10 percent of normal capacity results in end-stage kidney disease, which requires dialysis or a kidney transplant to sustain life. •____________________________. Damage to your kidneys and the resulting buildup of wastes in the bloodstream can raise your blood pressure. •____________________________. With this syndrome, too much protein in your urine results in too little protein in your blood. Nephrotic syndrome can be associated with high blood cholesterol and swelling (edema) of the eyelids, feet and abdomen GLOMERULONEPHRITIS •Primary- Cause by bacteria, viruses, fungi, parasites •Primary deals with kidney •Secondary the kidney involvement is ONLY part of a _______________ disorder •Develops from an excess _________________ response within the kidney tissue •Injures & Inflames _____________________- part of the kidney that filters the blood •Inflamed glomeruli allows protein and blood to pass in urine… associated with: •**_______ blood pressure & progressive kidney damage leading to CKD & edema •**__________ from reduced production of erythropoietin (decrease in RBC production) •**_______**cholesterol often occurs •Infection is usually noticed before-an average time of about ______ days after an infection •Assess signs of edema usually starts in ________, ___________, ____________.. •Assess for fluid overload & pulmonary edema- fluid in the lungs from fluid and sodium retention •Difficulty breathing or shortness of breath, check for _______________ in the lungs •_____ sounds or ________ •Urine color...may be smoky, reddish brown, rusty or coca cola colored • May have fatigue, lack of energy, anorexia, n/v if uremia present • How do you do a 24hr urine collection >>>CHRONIC •Manifests HTN, mild proteinuria & hematuria, fatigue & occasional edema are often the only symptoms -kidneys •Abnormally small in chronic-can see on X-ray or CT scan •Chronic Always leads to ESKD• •Collagen deposits & fibrosis. Microscopic exam shows deposit of immune complexes and inflammation •Kidney tissue atrophies & functional neurons decrease. Loss of nephrons reduce glomerular filtration •Monitor for circulatory overload •GFR is __________________

•Protein usually less than _____ grams in a 24 hour period •May have serum creatinine of 6mg/dL or > may be as high as 30mg/dL... •BUN can be as high as 100 to 200 mg/dL. •Develops hyp__phosphatemia & hyp__calcemia •Changes in serum Sodium levels usually _____, hyperkalemia •Monitor for metabolic acidosis- Healthy kidneys remove acid from the body through urine and they keep the right amount of bicarbonate (base) in the blood. But in CKD, the kidneys can’t remove enough acid, which can lead to metabolic ___________________. •As waste products collect in the blood may have changes in __________________ disturbed concentration, irritability or incapacity during job-related functions •Chronic- Monitor for uremic symptoms-tremors, slurred speech, ataxia, yellowish skin, texture changes, rashes, eruptions, bruises, itching (uremic frost), asterixis-flapping tremor of fingers

NEPHROTIC SYNDROME - Kidney disorder with _____________________PERMEABILITY •An immunologic, metabolic, biochemical, or physiochemical disturbance in the basement membrane of the glomeruli leading to: 1. MASSIVE _______________...(hyperalbuminuria) 3.5 grams in 24 hours •Which in turn decreases serum albumin causing 2. ______albuminemia- decreased plasma levels-Low Serum albumin levels less than 3gm/dL) 3. __________ formation (especially facial and periorbital) •Can see changes in the glomerulus but need an electron microscope (this is known as minimal change) •Cause is altered immunity with inflammation •Even Genetic defects of the filtering system (Fabry Disease) High serum ___________ – hyperlipidemia Lipids in the urine- lipiduria Hypertension Delayed clotting or increased bleeding with a higher than normal values for serum activated PTT, PT 8. Elevated BUN, Serum Creatinine and decreased GFR •May improve with suppressive therapy using steroids , cytotoxic and immunosuppressive agents •ACEis can decrease _____________ loss in the urine •Cholesterol lowering drugs can decrease _______________ •________________ may reduce vascular defects •Mild __________________ and sodium restriction may be needed to control hypertension and edema •If GFR is decreased may need decrease _______________________ in diet •AKI may be avoided if adequate blood flow to the kidney is maintained- assess for vascular dehydration 4. 5. 6. 7.

POLYCYSTIC KIDNEY DISEASE

- Fluid filled ____________ develop in the nephrons- the cysts look like clusters of grapes •Relentless development and growth of cysts from loss of cellular regulation & abnormal cell division result in progressive kidney ____________________ •Growing cysts damage the glomerular & tubular membranes •As cysts fill with fluid and become larger, kidney functions become less effective & urine formation and waste elimination are impaired •Most have ________ related to kidney ischemia from enlarging cysts. •The vessels are compressed and blood flow to kidney decreases. >>>>> The ___________ is activated raising blood pressure... •Control of _____________________is a top priority in order to prevent further kidney damage and avoid complications such as stroke from hypertension36 •Kidneys become the size of a football may weigh up to 10 pounds •The incidence of cerebral aneurysms (outpouching & thinning of an artery wall) is ________in patients with PKD, may rupture causing bleeding and **sudden death** •For unknown reasons PKD patients often have kidney stones, mitral valve prolapse, and colonic diverticula ETIOLOGY AND GENETIC RISK •Genetic disorder-most common inherited kidney disease • autosomal dominant (ADPKD) or autosomal recessive (those inheriting the recessive gene usually die in early childhood) •Autosomal _______________ most common -3 genes have been implicated in the cause of ADPKD (PKD1, PKD2, GANAB genes) •equal between men and women •HEMATURIA may be gross or microscopic •....UA-________________= decline in kidney function & impaired elimination •....UA-________________= infection(usually in the cysts)need to obtain a urine for C & S •__________ is often the first symptom...flank pain dull ache or sharp & intermittent....pain when a cyst ruptures... •A _________________ abdomen is common as cystic kidneys swell and push abdominal contents forward •Changes in urine color {_________&_________} and frequency...When cysts rupture...urine will be bright red or cola colored... •________________ suspected if urine is cloudy and foul smelling •NOCTURIA-due to decreased urine concentration abilities • Later on decreased GFR, water and sodium retention leading to HTN, edema & uremic symptoms such as anorexia, n/v, pruritus & fatigue •****Cerebral aneurysms...HTN, headaches, severe h/a with or without vision changes require attention •Manage HTN- ACEis effective. •Manage PAIN- Opiods and Acetaminophen, caution with _________; they can reduce kidney blood flow, ASA avoided due to bleeding risks...dry heat

NEPHROSCLEROSIS

•Degenerative disorder that is caused by _____________________ of the nephron blood vessels that supply the kidney, resulting in narrow lumens and decreased kidney blood flow •The tissue is chronically ________________ and fibrosis develops over time •Caused by: Atherosclerosis, HTN, DM •If diuretics used –maintain fluid and electrolyte imbalance •__________________ needs to be prevented when taking potassium sparing diuretics (such as spironolactone) HYDRONEPHROSIS Back up of Urine in ____________________ Due to obstruction of the renal pelvis •KIDNEY _________________ as urine collects -(because renal pelvis can only hold 5 to 8 mL)... Obstruction  distention •Kidney pressure ______________ as the volume of urine ______________ ...sometimes in a matter of hours the blood vessels and kidney tubules can be damaged extensively •Tubular Filtrate Pressure increases in the nephron as drainage through collecting tubules is impaired and the GFR decreases or ceases •KIDNEY NECROSIS can occur and NITROGEN waste products of (creatinine and BUN increase and electrolytes (sodium, chloride, potassium and phosphorus) are retained & acidbase balance is impaired •Hydroureter- includes ureter obstruction- where the iliac vessels cross or where the ureters enter the bladder •May be in metabolic ______________ RENAL CELL CARCINOMA •Adenocarcinoma most common type accompanied by ____________________ syndrome •Risk factors: More common in _______, 45+, family history, obesity, smoking, chemical exposure...cadmium and other heavy metals, asbestos, and benzene • ________________ sites are the adrenal glands, liver, lungs, long bones •Kidney cancer usually doesn't have s/s in ________ stages. s/s develop over time •Flank pain dull and aching...may be more intense if ___________ into the tumor or kidney occurs, May even have a palpable kidney mass, A renal bruit may be heard •Muscle wasting...Muscle weakness...Unexplained weight loss...occur later in the disease, Hematuria can occur as well but often times is also a late sign •Systemic effects (PARANEOPLASTIC SYNDROME- anemia, erythrocytosis, hypercalcemia, liver dysfunction, , elevated liver enzymes, ^ ESR and hormonal effects and HTN •Cause of the anemia & erythrocytosis- occurs from kidney cell production of erythropoietin •(At times the Kidney tumor cells produce LARGE amounts of erythropoietin causing ______________________) (At other times the tumor cells destroy the erythropoietin producing kidney cells causing __________________) •___________________ is PRODUCED & RELEASED by tumor cells can cause hypercalcemia •The release of ___________ can cause HTN •Release of an increase of _______________________________ decrease libido and change in secondary sex features, gynecomastia and darkening of the nipples TREATMENT •___________________________ can provide a cure if cancer is local

•Renal cell tumors are highly ______________ and blood loss during surgery is a major concern...the arteries supplying the kidney may even be embolized by interventional radiology to reduce bleeding during nephrectomy •Decrease in _______ is an early sign of hemorrhage as well as ADRENAL INSUFFICIENCY •With hypotension urine output is _______________****Large H20 and Na losses fluid & electrolyte imbalance •Monitor vital signs for signs of bleeding especially ____ in BP or ____ in pulse rate, monitor abdomen for distension may also signify bleeding, monitor dressings and drainage tubes, nephrostomy tube drainage may be dark pink or red for about 24 after insertion but will gradually clear •MONITOR I & O every 1 hr for first 24 hours, Output dropping below 30 to 25 mL/hr suggests DECREASED BLOOD FLOW to the kidney and the kidney is NOT GETTING PERFUSED and can lead to AKI •Decreasing BP and Urine output may be signs of adrenal insufficiency and may need cortisol replacement need ____________________________ •Pain management is needed to help patient be able to take deep breaths and cough to prevent ____________________& ____________________ •Monitor for signs of infection, fever, chills increasing WBCs, monitor dressing site and tube drainage •Having one kidney should be able to provide adequate function but may take a couple weeks KIDNEY TRAUMA •Prevent kidney injury: wear seat belts, wear protective gear when participating in sports, use caution when riding a bile or motorcycle, safe walking practices-no headphones.don’t be on phone, No contact sports if only one kidney •May occur with penetrating wounds or blunt trauma to the back, flank, or abdomen •____________ trauma accounts for most kidney injury •It is classified in 5 grades Stage I- kidney bruising Stage 2 Stage 3 Stage 4 Stage 5 shattering of the kidney to tearing of the kidney’s blood supply •HEMATURIA is not normal and hemorrhage can be life threatening •*Report Bleeding before catherization to prevent further complications MYOCARDIAL INFARCTION •Understand__________________ is associated with decreased blood flow to the heart and an MI indicates ____________________ of heart muscle tissue (see chart 38-2) •physical changes of the heart with an infarction starting within the first 4 to 6 hours

•Understand Percutaneous Coronary Intervention

•What is actual hemodynamic monitoring (Is it invasive?)

• Do not give beta-blockers if the patient has a low _________ rate •What needs monitoring for patients on anti-platelets?

•Be aware of medications used for erectile dysfunction (phosphodiesterase inhibitors) concomitant use can cause profound hypertension •Where should topical nitrates be administered- where should they be placed on the body •What medications are given to prevent fibrinogen from attaching to activated platelets at the site of a thrombus •Know the ROLE of Aspirin in increasing myocardial perfusion

•What needs monitoring during and after Thrombolytic Therapy •What signs and symptoms does the nurse monitor in order to detect inadequate organ perfusion that may result from decreased cardiac output •90% of sudden cardiac arrest victims die before reaching the hospital •Many of the deaths are attributed to _________________________________ •___________________________-Chest pain caused by a temporary imbalance between the coronary arteries; ability to supply oxygen and the cardiac muscle’s demand for oxygen •__________________________________-Limited in duration....