Nur 265 Test 1 Study Guide (Answered) Complete Solution

Nur 265 Test 1 Study Guide (Answered) Complete Solution Med Math ● The MD orders drug X at 6mcg/kg/min. Your pt weighs 175 pounds. Pharmacy sends the medication to the unit with a concentration of 500mg in 250mL. What is your mL/hr? ml/hr = 250 ml/500 mg X 1 mg/1000mcg X 6 mcg/kg/min X 1 kg/2.2 lb X 175 lb X 60 min/ 1 hr = / = 14.31 = 14.3 ml/hr Labs ● Hbg 12-18 ● Hct 37-52% ● WBC 5-10 ● RBC 4.2-6.1 ● PLT 150-400 ● PT 11-12.5 sec (1.5-2.5x normal on Coumadin = 16.5-31.25 sec) ● INR 0.9-1.2 sec (Therapeutic level 2-3x normal = 1.8-3.6 sec) ● PTT 60-70 sec (1.5-2.5x normal on Heparin = 90-175) ● Na 135-145 ● K+ 3.5-5 ● Creatinine 0.5-1.2 ● BUN 10-20 ● Total Protein 6.4-8.3 ● Albumin 3.5-5 ● Mg 1.5-2.5 ● Ca 9-10.5 ● Cl 98-106 ● Phosphorus 2-4.5 ● GFR 90-120 ● T1 0-0.1 ● TT 0-0.2 ● BNP 100 = HF ● Specific Gravity 1.005-1.030 Nephrotic Syndrome ● Increased glomerular permeability that allows larger molecules to pass through membrane. ● Signs & Symptoms o Find in urine ▪ *Massive protein loss, severe proteinuria ( 3.5 g of protein in 24 urine sample) ▪ Lipiduria (Lipids in the urine) o Find in Blood ▪ Hypoalbuminemia 3 g/dl (low serum albumin[protein]) ● Facial/periorbital edema (w/o albumin in cells, fluids leak out of vessels) ▪ Hyperlipidemia (high serum lipid levels) – due to low albumin ▪ Increased coagulation ● Treatment o Depends on what the cause is, if immune give steroids o Maintain fluid and electrolyte balance; daily weights, strict I&Os & abd girth measuring ▪ BP measures if enough fluid in cells o Furosemide & bumetadine w/ albumin, plasma, dextran o Sodium and Potassium restriction if labs warrant o Anticoagulation to prevent renal vein thrombosis – Enoxaparin o ACE inhibitors to decrease protein loss in urine o Cholesterol-lowering drugs o Restrict protein intake to 1-1.5 g/kg/day w/ high caloric diet to prevent further protein breakdown, but give enough to maintain muscle health. ● Increased r/f infection and slowed wound healing d/t protein deficit. ● Osteomalacia (body takes Ca from bones) – Ca is bound to albumin, so it is decreased too. Acute Kidney Injury (AKI) ● Rapid reduction in kidney function resulting in failure to maintain Fluid & Electrolyte & Acid Base Balance. ● Causes o Pre-renal (most common cause) – Decreased blood flow to kidney w/ decreased GFR ▪ Hypovolemia, AMI, Hypotension, Vasodilation, Renal Artery Obstruction (clot) o Intra-renal – Direct kidney damage, usually the tubules from nephrotoxic substances ▪ Antibiotics, heavy metals, poisons, contrast dye (CT scan), some analgesics, NSAIDS, Chemo ▪ Car accident, infection in kidney (pyelonephritis), Lupus, Cancer ▪ Damaged muscle can release heme & myoglobin, can cause tubule damage (rhabdomyolysis) ● Urine turns brown after traumatic kidney injury o Post-renal – Backward pressure on kidney from obstruction somewhere in lower urinary system ▪ Bladder, Cervical, Colon or Prostate Cancer; Enlarged Prostate (hypertrophy); Kidney Stones; blood clots in urinary tract. ● Phases of AKI o Onset: Initial event to development of manifestations, immediate to week before sx. o Oliguric – Anuric: 1-8 weeks, the longer lasts worse prognosis. Up to 2 mon diminished function ▪ Ex: NPO b4 surgery can cause ▪ Urine amounts 400cc/24hrs ▪ Gradual buildup of nitrogenous wastes (azotemia) ▪ Manifestations of fluid overload (Crackles, edema, decreased O2, increased RR, dyspnea) ▪ Elevated ● Serum Creatinine (0.6-1.2) ● BUN (10-20) ● K (3.5-5) ● Phosphorus (phosphate) (2-4.5) ● Magnesium (1.5-2.5) ▪ Decreased ● Na (135-145) – due to dilutional effect ● Ca (9-10.5) ● Metabolic Acidosis (7.35-7.45) - Bicarb to tx short term, dialysis to tx severe. o Diuretic: Gradual or abrupt return of GFR & leveling of BUN, lose 1-2L a day of urine ▪ Hypovolemia and electrolyte imbalance (balance is key to survival) o Recovery: Lasts 3-12 months ● Uremic Encephalopathy – Build up in urea and poison brain, decreased LOC ● Assessment is key to prevention and early intervention (restore volume) o For pts at risk: Hypotensive, surgery, hypovolemic (burns, MVAs, hemorrhaging) or pt w/shock ● Seizure precautions (elevated BUN), infection prevention, High calorie, low protein, low K, Na, Mag, Phos. ● Renal Dialysis or CRRT if pt. can’t tolerate (runs 24 hrs at bedside) ● Meds o Dopamine – Dilates renal artery and increases blood flow o Diuretics – furosemide & mannitol for fluid overload but use cautiously o Hyperkalemia acutely tx w/ ▪ 1st – Calcium Gluconate ▪ 2nd – Glucose, insulin & bicarb combo ▪ Forces K intracellularly for a short time to prevent cardiac complications o ABX to prevent infection (NO Aminoglycosides –mycin, tetracycline, Methicillin, Rifampin, Sulfonamides) o Calcium Chanel Blockers may be used to tx AKI resulting from nephrotoxins ● Daily weights and strict I&O ● Decreased Urine Specific Gravity (1.005-1.030) is earliest sign of AKI Hemodialysis ● Hypotension is major issue with hemodialysis and up to 30% of pts can’t tolerate. ● 2-3x a week for 2-3 hours ● Pt needs large vascular access – AV Fistula, shiley catheter (jugular, subclavian, femoral) ● Disequilibrium Syndrome o Caused by rapid changes in fluid volume and electrolytes o S/S – H, malaise, grumpy, exhausted, n/v, restlessness, decreased LOC, seizures, coma, death o CRITICAL! – Early tx w/ anticonvulsants (ethosuximide, gabapentin) & barbiturates (phenobarbital) ● Anticoagulation needed ● Weigh pt b4 and after, know pt. dry weight, certain drugs withheld b4 (BP drugs, vitamins, etc), Assess VS ● AV Fistula o Surgical connection of artery to vein, up to 4 months to mature o Need temporary vascular access (AV shunt or HD catheter) o No BP or sticks o Palpate thrills & auscultate bruit q4 hrs and assess pulses o Elevate postoperatively o Check for bleeding and assess for manifestations of infection o No carry heavy objects or sleep on extremity, no pressure on it o Chlorhexidine before access o Teach pt to wash area w/antibacterial soap & h2o between sessions ● HD Catheter o Subclavian, jugular, femoral o Aseptic technique o Heparin dwell solution after dialysis tx, DO NOT USE FOR ANYTHING BUT DIALYSIS TX. o If used in emergency make sure to waste 10cc from catheter before use. o More time needed for dialysis tx (4-8 hrs) because smaller than AV fistula CRRT (Continuous Renal Replacement Therapy) ● Dialysis slowly over 24 hrs at bedside by trained RN ● Safer for brain injury, Cardiovascular DOs, and pts who can’t tolerate hemodialysis ● Clots easy! Must be anticoagulated (Heparin) Peritoneal Dialysis (PD) ● Repeated cycles of 1-3L of fluid instilled into abd, allowed to dwell for a period of time then drained ● Can be done at home and effective for years ● Good for those who can’t handle anticoagulation ● Can be complicated by scars and infection ● Warm fluid to prevent pain form cramping, NOT in microwave! ● R/f hypoalbuminemia due to albumin crossing peritoneal membrane especially if pt infected. ● Peritonitis major complication (fluid coming out should be color of urine, not cloudy or fowl smelling) o Cloudy or opaque effluent is earliest sign of peritonitis. o Sterile technique - mask ● Respiratory Distress w/ large fluid volumes Chronic Renal Failure ● Irreversible & progressive reduction of functioning renal tissue. ● ESRD – Stage 5 o Diabetes is leading cause, 30% of pts who receive dialysis. o BUN (10-20) & Creatinine (.5-1.2) increase as waste products of protein metabolism accumulate. o Serum creatinine level is the MOST ACCURATE measure of renal function o Proteinuria ▪ Decreases intravascular osmotic pressure (fluid leaks) o Anemia ▪ Erythropoietin & blood transfusions o Metabolic Acidosis (kidneys secrete excessive hydrogen ions [acid]) ▪ Oral sodium bicarb tabs o Hyperlipidemia ▪ Due to changes in fat metabolism. Increase pt r/f CAD & acute cardiac events o Hyperkalemia ▪ Kayexalate & diet restriction o Hyperphosphatemia ▪ Phosphorus Restriction (high phosphorus causes low Ca) ● Administer phosphate binders at meal times (calcium acetate/carbonate, lanthanum carbonate, sevelamer) These drugs can cause constipation o Bone Disease ▪ Due to Ca being released from bones from high phosphorus causing hypocalcemia ▪ Vit D is synthesized in the kidney so w/o it Ca less absorbed in intestinal tract o Protein energy malnutrition o Neuropathy o HTN o Carb intolerance - impaired insulin production o Muscle cramps o Pericarditis from uremic toxin buildup o Bleeding occurs as disease progresses due to platelet abnormalities from uremic toxins ● Azotemia – Buildup of nitrogenous wastes in blood ● Uremia – azotemia w/ clinical s/s – Uremic Syndrome o Change in taste of foods (sweets not appealing, meats metallic taste), anorexia, n/v, muscle cramps, uremic frost (on skin), itching, fatigue, lethargy, hiccups, edema, dyspnea, paresthesia ● Treatment/management o Dialysis o Renal Transplant o Radical Nephrectomy o No magnesium based antacids o Sodium, protein (protein waste product buildup main cause of uremia) & cholesterol restriction o Weight management, daily weight & fluid restrictions o Blood pressure control is essential in preserving kidney function ▪ CCB (improve GFR), ACE, (mist effective in slow progression of CKD in pts with HTN) o Medications ▪ Loop Diuretics - Furosemide (Lasix) & Bumetanide (Bumex) ● Manage fluid overload when urinary elimination is still present ▪ Phosphate Binders – Calcium acetate, Calcium carbonate ● Bind to phosphorus and excrete in feces, can cause constipation ▪ Aluminum hydroxide gel - Amphojel ● Take with meals, stool softeners, report: muscle weakness, slow or ireg pulse, confusion ▪ Vitamins – Folic Acid, Iron (Ferrous Sulfate), Vit D (Calcitriol) ● Take after dialysis, take stool softeners ● Calcitriol – Active form of Vit D, suppresses parathyroid production and secretion. ▪ Erythropoietin – Epoetin alfa, Darbepoetin alfa ● Stimulates RBC production in bone marrow ● Report S/e – chest pain, dyspnea, high BP, rapid weight gain, rash/hives, edema