NRNP 6550: Advanced Care Of Adults In Acute Settin, Final Exam Questions and Answers Latest 2024 (Graded A+)

NRNP 6550: Advanced Care Of Adults In Acute Settin, Final Exam Questions and Answers Latest 2024 (Graded A+)Urine culture with UTI: 100.000 colonies in asymptomatic: bacteruria 10 - 10.000 colonies in symptomatic patients but also pyuria pyuria: more than 10 leukocytes elevated erythrocytes with pyelonephritis WBC in urine false positive with tumor, urethritis and poor collection technique Repeat in pregnant women 2. Lower urinary tract UTI and upper urinary tract UTI: bladder and urethra: cystitis/ urethritis/ prostatitis kidney and ureters: pyelonephritis/ renal abcess 3. Uncomplicated and complicated uti: Uncomplicated: in normal working urinary tract Complicated: defects in urinary tract or with other health problems 4. Common pathogens for UTI: E.coli (elderly women) Staphylococcus proteus mirabilis (elderly men) Klebsiella enterecoccus pseudomonas Providencia (institutionalized) Fungus: candida 5. Risk factors for UTI: Female critically ill elderly catheter (caused by biofilm) DM calculi, tumor, stricture neurogenic bladder Women: sexual intercourse or new sex partner pregnancy previous UTI Men: prostate enlargement prostatitis lack of circumcision 2 / 52 NRNP 6550 Final Exam Latest gay HIV 6. Findings UTI: Lower: Dysuria/ urgency/ frequency/ incontinence suprapubic pain hematuria fever/ chills uncommon No flank pain Upper: flank pain fever and chills hematuria n/v ams (in elderly) malaise tachycardia/ tachypnea 7. Testing and results for UTI: Gold standard: urine culture and sensitivity: detection of bacteria. Start with POC: urine analysis. UA: pos for nitrite or leukocyte or blood CBC: leukocyte with left shift in pyelonephritis For recurrent UTI in women or UTI in men rule out obstruction, calculi, or necrosis with: xr voiding CT abdomen US pelvis MRI pelvis 8. Management acute cystitis: First line: - Single dose Fosfomycin (monurol) - 3 day: sulfa: trimethoprim/ sulfa (bactrim) (do not give near delivery of baby, give cephalexin instead) or sulfa - 5 days: nitrofurantoin, caution in elderly Second line: - qiunolones: ciprofloxain or levofloxacin for 3 days (not for pregnant women!) - B-lactams: amoxi-clav, cefdinir for 3 - 7 days 9. Management uncomplicated upper UTI: Outpt: quinolone: ciprofloxacin for 7 days or levofloxacin for 5 days 3 / 52 NRNP 6550 Final Exam Latest Sulfa: trimethoprim/ sulfa (bactrim) for 14 days Inpt: Ceftriaxone or cefotaxime Ampicillin CAUTI: bacterial: treat with AB for 7 days Candiduria: fluconazole for 14 days Discomfort: Pyridium 10. Management acute complicated bacterial pyelonephritis: - Admit - Aminoglycosides: gentamicin/ tobramycin (not for monotherapy), based on renal function (trough less than 2 and peak level 5-10mg/L) and do not give for CKD - Ampicillin - Cefazolin - Cefotaxime and Ceftriaxon based on obesity and pulm disease 11. Urine analysis: glucose and ketones: Serum glucose at least 180mg/dl for glucose to appear in urine Glucose in ua caused by: - Fancone Syndrome (bad wall: caused by ahminoglycosides for example) - DM - Cushing's - Vit C can give false negative Ketones in urine: - Alcohol - Diabetic - Starvation 12. Acute Kidney Injury: -Acute renal function loss with inability to excrete metabolic waste products (urea nitrogen and creatinine) to inability to maintain fluid and electrolyte balance. - Resolves within 3mo - classified with RIFLE or etiology 13. RIFLE: Risk: creatinine up x 1.5 from baseline, GFR decrease more than 25% and UO less than 0.5ml/kg/hr for 6hr 4 / 52 NRNP 6550 Final Exam Latest Injury: creatinine up x 2 from baseline, GFR decrease more than 50% and UO less than 0.5ml/kg/hr for 12hr Failure: creatinine up x 1.5 from baseline, GFR decrease more than 25% and UO less than 0.3ml/kg/hr for 12hr or anuria for 12hr Loss: Complete loss of renal function for more than 4 weeks End-stage Kidney Disease: RRT need for more than 3mo 14. Prerenal renal failure: Most often the cause of RF - Decreased blood supply; intravascular volume depletion, vasodilatory states - Increased tubular sodium and water reabsorption, causing: oliguria, decreased urine sodium, high urine osmolality, increased urine specific gravity caused by: 1. Low CO 2. Hypovolemia 3. RAS (renal artery stenosis) 4. aminoglycosides, NSAIDS Result: - low urine volume - increased urine creatinine with normal serum creatinine - minimal proteinuria - serum K moderately increased - serum phos moderately increased - serum calcium normal - normal renal size on US 4. Low Na+ 5. Low H2O 6. High osmolality (500 and up) 7. High uric acid 8. Specific gravity: greater than 1,010 9. Urinary sodium: less than 20 10. Sediment*: 0 (hyaline casts) 11. BUN/ creat ratio: greater than 10/1 15. Intrarenal: Cause: - Ischemia or nephrotixic injury (rhabdo, multiple myeloma, aminoglycosides, 5 / 52 NRNP 6550 Final Exam Latest chemo, contrast) - Necrosis (acute tubular necrosis ATN) (prolonged hypotension, low CO, liver disease) - Acute tubulointerstitial nephritis from bacterial pyelonephritis, drug-induced, immunologic disorders - oliguric/ anuric - decreased urine creatinine - no proteinuria - serum creatinine increased - serum K increased - serum phos increased - serum Calcium decreased Low Na+ High H2O Low osmolality (350 and less) Specific gravity: 1,010 Urinary sodium: greater than 20 Sediment: + BUN/ creat ratio: less than 20/1 FEna: greater than 2% Treat: stop offending drug. Contrast: fluid administration, pre- and post. Hold metformin before contrast, for 48hrs. 16. Postrenal: Cause: Urinary flow obstruction: Enlarged prostate Cervical cancer Tumors Kidney stones Neurogenic bladder, diabetic neuropathy, spinal cord disease - urine creatinine decreased - no proteinuria - no sediment or hematuria with stones - BUN increased - serum creatinine increased - serum phos increased - serum calcium decreased 6 / 52 NRNP 6550 Final Exam Latest Anuria/ polyuria Urine osmolality less than 350 Fixed urine specific gravity (1.0008- 1.012) Urine Na greater than 40 BUN to creatinine ratio: greater than 20:1 Treat with catheter drainage, urethral stents, percutaneous nephrostomy 17. treatment of ARF/AKI: -· Therapy for ARF: o Treat underlying cause o Correct fluid, electrolyte, uremic abnormalities o Prevent complications o Lasix can be given for volume overload (due to oliguria) o Patient can become nutritionally deficient as ARF is a catabolic state. Total caloric intake: 30 - 45 kcal/kg/day. Protein restricted when not on dialysis: 0.6g/ kg/day. If on dialysis protein should be 1-1.5g/kg/day. Diet should be low protein/ Na/ K o Dialysis, often needed. Especially when BUN greater than 100 and serum creatinine greater than 5 - 10, acidosis/ alkalosis, hyperkalemia o Metabolic acidosis: treat with IV (or oral) bicarb when serum HCO3 is less than 15, or PH less than 7.2 o Renal transplant 18. Treat renal failure complications: which and how: Hyperkalemia: - Kayelxalate 15-30 g with 100 ml sorbitol: enema - IV calcium: cardioprotective - Insulin (10units) with 25 g glucose - IV sodium Bicarb (150 mEq in 1 lt) - dialysis in significantly elevated K (greater than 7) Hyperphosphatemia: - Keep below 4.6 - Restrict phos (cola, eggs, dairy, meat) - Give calcium carbonate (650mg TID) - Renvela (Sevelamir) - Calcium acetate - Dialysis Hypocalcemia (ion Ca less than 1.12): - Calcium carbonate supplements - maintain phos at 6 7 / 52 NRNP 6550 Final Exam Latest Hypermagnesemia Avoid mag. laxatives Fluid overload: - Decrease Na and fluid intake and give lasix HTN: Goal: 140/80 unless proteinuria than 125/75 ACE-inhib, calcium blockers if proteinuria present, hydralazine, B-blocker Protein catabolism: - Limit protein intake: less than 8gr/, avoid stress and not too much physical activity Acidosis Give sodium citrate when HCO3 below 20 Anemia - give iron - give erythropoietin injection 19. RRT option in AKI and CKD: - Hemodialysis (intermittent (MAP of at least 60mmHg), continuously venous or arterial) - Peritoneal dialysis - for long term use. Does not achieve adequate creatinine clearance (may be switched to hemodialysis in acute care situations) and high risk for infection 20. chronic kidney disease: · Chronic kidney disease: GFR 60ml/ min or less for longer than 3mo. o HTN common o US with show bilat small kidneys o Cause: § HTN nephropathy § Diabetic nephropathy § Renal artery stenosis § Glomerular disease o When GFR between 5 - 10: dialysis o Creatinine clearance: age and gender-dependent. Males: 97-137, Females: 8 / 52 NRNP 6550 Final Exam Latest 88-128 o Signs/ Symptoms: - Fatigue/ weakness - Pruritis - bruising - dyspnea on exertion - HTN - Metallic taste - SOB/ pleural effusion - n/v with anorexia - impotence/ nocturia - peripheral neuropathy - anemia (due to erythropoietin deficiency) 21. Stages of CKD: o Stages - 5 stages 80 - 120 ml/min § 1: GFR greater than 90 § 2: GFR 60 - 89 § 3: GFR 30 - 59 § 4: GFR 15 - 29 § 5: ESRD GFR less than 15, uremia, cardiovascular disease. 22. Modification of drug dosages based on kidney function: serum creat greater than 10mg/ml: major modification serum creat 3-10 mg/ml: modest changes 23. Types of drugs and kidney function: Type A: eliminated by kidney entirely Type B: eliminated by extrarenal entirely Type C: eliminated by renal and extrarenal 24. Decreased renal function results in:: abnormal excretion rates abnormal metabolism rates abnormal sensitivity to drugs 25. benign prostatic hyperplasia: enlargement of prostate gland in men older than 50yrs, interfering with urinary flow by obstructing the urethra (straining, frequency, dribbling, incontinence, nocturia) 26. Diagnosis of bph: definition and symptoms: Prostate enlargement during digital rectal exam (if nodules or hardness is felt than concern for malignancy) - Avoid meds that worsen symptoms (decongestants, diuretics, anticholinergic, tricyclic antidepressants, opiates - Give Alpha blockers, such as terazosin, prazosin, tamsulosin and hormonal 9 / 52 NRNP 6550 Final Exam Latest stimulation, such as finasteride - surgery: TURP, TUIP, prostatectomy 27. PSA: prostate-specific antigen: prostate ca risk Level between 4 - 10: 25% risk above 10, more than 50% risk 28. Crockcroft-Gault equation: deterination of renal function through gfr. Males: creatinine clearnace = (140 - age) x (body weight kg) / (72 x serum creatinine) Females: creatinine clearnace = (140 - age) x (body weight kg) / (72 x serum creatinine) x 0.85 29. Renal function and older age: - diminshed kidney mass, blood flow, gfr - reduced bladder elasticity, muscle tone, and capacity 30. renal artery stenosis: Renal artery stenosis causes ischemia in artery providing the affected kidney with blood. In turn the kidney will produce renin which causes HTN. Kidney will also shrink (atrophy): ischemic nephropathy. Long term it can lead to chronic RF. 31. Renal artery stenosis: signs, tests, management: · Signs: sudden or unexpected HTN epigastric bruits edema increase/ decrease urine itching dry skin n/v muscle cramping unexplained hf/ pulm edema decline in gfr metabolic acidosis · Tests: doppler/ ultrasound and CT-angio of renal arteries (risk of contrast induced nephropathy) · Management: o Life-style changes o Meds to optimize glycemic control, blood pressure, cholesterol o ACE-inhibitors (Pril), ARB's (tan) (further decline in GFR may occur) o RAAS-blockade (ACE and ARB), statin, aspirin: cornerstone therapy o Check kidney function after two weeks of starting ACE and ARB: may cause 10 / 52 NRNP 6550 Final Exam Latest acute RF. o Diuretic, beta-blocker, or calcium channel blocker might be needed as well - revascularization of kidneys through PTA (with stent) - endarterectomy - assess for CAD 32. nephrolithiasis: definition, risk factors: - stones in pelvis, kidney or ureter - male, age 30 and up - previous calculi - dehydration - stress - diet: high sodium, high protein, high fructose, low calcium - obesity - dm - sarcoidosis - gout - uti - chemo/ steroids/ vit d supplements 33. types of renal calculi: - Calcium stones (most common) - Hypercalciuric calcium nephrolithiasis, caused by absorptive (bowel absorption of calcium), resorptive (hyperparathyroidism causing hypercalcemia) and renal (no filtering of calcium) disorders - Hyperuricosuric calcium nephrolithiasis (excess uric acid in diet, such as alcohol and fish) - Hyperoxaluric calcium nephrolithiasis (intestinal disorder) - Hypercitraturic calcium nephrolithiasis - uric acid calculi - struvite calculi - cystine calculi 34. Findings with nephrolithiasis: - acute flank pain - testicular pain - n/v - frequency/ dysuria/ oliguria/ hematuria - Gold standard: noncontrast helical CT - renal us, less sensitive - ua: blood - wbc increased