NUR 265 Exam 1 Content Review, Complete Solution

NUE 265 Exam 1 Content Review, Complete Solution EXAM #1: CONTENT REVIEW Unit 1: Care of Patients with Complex Renal & Gastrointestinal Problems Renal A & P • What do the kidneys do? o Kidneys receive 20-25% of cardiac output under resting conditions – more than 1L blood/min o Kidneys are controller of fluid & electrolyte homeostasis in the body o Kidneys secrete erythropoietin that inc. RBC synthesis in bone marrow o Kidneys convert Vitamin D into its active form o Loop of Henle concentrates urine and allows water reabsorption into bloodstream Question: The nurse is explaining to a group of nursing students that when there is a decrease in the secretion of renin, and aldosterone it can cause ▪ (Select all that apply.) • A. an excretion of sodium. • B. dilution of urine. • C. increased intestinal absorption of calcium. • D. increased bone density. • E. a decreased thirst. Physical Examination • Skin color (ashen, yellow); crystals on skin (uremic frost) • Tissue turgor: to detect dehydration or edema • Periorbital edema: suggests fluid retention. Inspect the mouth for moisture and odor • Observe respiratory rate, pattern, and effort • Auscultate the lungs for crackles or rhonchi • Inspect the abdomen for scars and contours, and palpate for tenderness and bladder distention • Edema • Inspect the genitalia Nephrotic Syndrome • Patho: o A condition of increased glomerular permeability that allows large molecules to pass through the membrane into the urine and then be excreted. o This process causes severe proteinuria, high serum lipid levels, fats in the urine, edema and hypertension. o Identified by kidney biopsy • Risk Factors: allergic reactions, reactions to medications, renal vein disease, sickle cell disease, HF • Clinical Manifestations o Massive proteinuria (Increased protein) 3.5g/day in a 24-hour urine sample o Hypoalbuminemia (Decreased albumin (serum)) 3g/dL o Hypertension o Edema (esp. facial and periorbital) o Hyperlipidemia (due to low albumin) o Fat bodies in urine o Delayed clotting or increased bleeding with higher-than-normal values of serum activated partial thromboplastin time (aPTT), coagulation or internation normalized ration for prothrombin (INR, PT) o Reduced kidney function with elevated BUN and serum creatinine and decreased GFR • Nursing Interventions: management varies, depending on which process is causing the disorder! o Maintain fluid (NS) & electrolyte balance o Monitor labs daily o Monitor and record I&O daily o Assess daily weight o Restrict sodium & potassium intake (diet changes) o Monitor skin due to edema o Protein intake restriction with decreased GFR; normal GFR dietary intake of protein is needed! o Medications: ▪ Administer steroids if needed for inflammation ▪ ACE inhibitors: Can decrease protein loss in the urine ▪ Cholesterol-lowering drugs can improve blood lipid levels • NOTE! NS may progress to end stage kidney disease (ESKD) but can be prevented with treatment!! Kidney Injury • Acute (AKI) vs Chronic (CRF) o Acute develops in a few hours to days with abrupt disruption in kidney function o Chronic is progressive deterioration over years with slow loss of kidney function o AKI affects MANY body systems. Chronic kidney disease affects EVRY body system. AKI • What is it? o Rapid reduction in kidney function resulting in a failure to maintain fluid & electrolyte balance, and acid-base balance. o Develops abruptly within hours to days o If AKI occurs in patients with decreased kidney function already  ESKD o Increase in serum creatinine by 0.3mg/dL or more within 48 hours; OR increase in serum creatinine to 1.5 times or more from baseline ▪ Occurred in previous 7 days; or a urine volume less than 0.5 mL/kg/hr for 6 hours o GFR is not accurate acute or critical illness although best overall indicator of kidney function! o HYPOPERFUSION (reduction in blood flow) ▪ Kidney compensates by constricting blood vessels and by activating renin-angiotension- aldosterone which RELEASES ADH ▪ ADH- increase blood volume increasing perfusion BUT will decrease UOP causing: • OLIGURIA = 400ml/24hour period o Less than 0.5mL/kg/hr for 2 or more hours o Min. UOP Q24 hours=720mL or 30mL/hr ▪ Symptoms of reduced blood volume  MAP 65, tachycardia, thread peripheral pulses, decreasing cognition o Timely interventions to remove the cause of AKI may prevent progression to ESKD and the need for lifelong renal replacement therapy or a renal transplant • S/S: same as fluid overload  Hypertension, dec. O2, high HR • AKI Causes o Reduced perfusion to the kidneys, damage to kidney tissue and obstruction of urine outflow o Pre-renal: decreased perfusion to glomeruli ▪ Reduced perfusion with a sustained mean arterial pressure (MAP) of less than 65mm Hg ▪ Conditions that contribute: Blood or fluid loss, BP drugs, heart attack/HF, infection, liver failure, use of aspirin/ibuprofen/NSAIDS, dehydration, burns, atherosclerosis o Intra-renal: nephrotoxic agents, kidney infections, occlusion of intrarenal arteries, hypertension, diabetes mellitus, or direct trauma to the kidney ▪ Reflects injury to the glomeruli, nephrons or tubules ▪ Conditions that contribute: glomerulonephritis, bleeding in the kidney, sepsis, lupus, TTP, drugs, multiple myeloma, scleroderma, vasculitis o Post-renal: caused by backward pressure on the kidney from an obstruction somewhere lower in the urinary system (Effects normal urine flow) ▪ Conditions that contribute: Kidney stones, cancers (bladder, cervical, colon, prostate), enlarged prostate, nerve damage, blood clots in the urinary tract Table 68-4 Conditions Contribute to AKI • Prerenal (Perfusion Reduction) o Blood or fluid loss (surgery, trauma, sepsis, shock, hypovolemic shock) o BP drugs resulting in hypotension o MI or heart failure o Infection o Liver failure o Use of aspirin, ibuprofen, Naproxen, NSAIDS o Severe allergic reaction o Severe burns o Severe dehydration o Renal artery stenosis o Bleeding or clotting in kidney blood vessels o Atherosclerosis or cholesterol deposits that block blood flow • Intrarenal (Kidney Damage) o Glomerulonephritis or inflammation o Bleeding in kidney o Thrombi or emboli o Hemolytic uremic syndrome (premature destruction of RBC’s) o Sepsis & local infection o Lupus o Chemo agents, abx, iodinated or hyperosmolar contrast, zoledronic acid o Multiple myeloma o Scleroderma o Thrombotic thrombocytopenic purpura o Ingested toxins (etoh, heavy metals, cocaine) o Vasculitis o Ischemia in kidney tissue • Postrenal (Urine Flow Obstruction) o Bladder, cervical, colon, prostate cancer o Enlarged prostate o Kidney stones o Nerve damage involving nerves that control bladder o Blood clots in urinary tract • Phases of AKI o Onset stage: from time of initial event to renal manifestations, symptoms can occur immediately up to a week after event ▪ increased BUN & serum creatinine with normal to decreased urine output. o Oliguric stage: can last 1 to 8 weeks (the longer this phase last the worse the prognosis. ▪ urine output decreases to 400 mls or less per day o Diuretic stage: gradual or abrupt return of glomerular filtration. ▪ Urine output may be 1-2L per day. Serum BUN & creatinine levels decrease. • Need a place of care that focuses on fluid and electrolyte REPLACEMENT and monitoring. • Onset of polyuria can signal the start of recovery from AKI. o Recovery stage: as renal tissue recovers, serum electrolytes, BUN & creatinine return to normal. ▪ Can last 3-12 months • Nursing Care of Patients with AKI o Avoid hypotension and maintain normal fluid balance to prevent and manage AKI o Thorough assessment and close monitoring of laboratory values is essential for signs of impending kidney dysfunction. (Na, K, USG, albumin creatine ratio, osmolarity, BUN and electrolytes) ▪ Evaluate fluid status ▪ Accurately measure I&O ▪ Measure body weight ▪ Note characteristics of urine (report of new sediment, hematuria (smoky or red color)), foul odor ▪ Report urine output 0.5 mL/kg/hr for more than 2 hours  ACT EARLY! ▪ Monitor kidney lab values • Increase in creatinine, esp. over hours or a few days (report to PCP) • BUN • Potassium, sodium, urine specific gravity, albumin-creatinine ratio and electrolytes • Reduced GFR makes pt more vulnerable for AKI ▪ Keep MAP at 80 mm/hg ▪ NO nephrotic agents ▪ Check kidney function before contrast dye • When nephrotoxic agents are