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AH II
renal & burns
| question | answer |
|---|---|
| bun | 10-20 mg/dl |
| creatinine | 0.6 - 1.5 |
| normal BUN/ creatinine ratio | 10: 1 |
| KUB | kindney-ureter-bladder x-ray; no contrast; may need bowel prep; painless |
| CT scans | masses; metastasis; lymphadenopathy |
| MRI | more sensitive in differentiating cysts vs neoplasms |
| IVP | intravenous pyelogram; uses contrast medium; evaluates the entire urinaty tract |
| pre- procedure IVP | assess for iodine allergies (steroids can prevent this, antihistamines); asess creatinine; bowel prep manditory by 6 pm; NPO after mindnight; salty or metalic taste with dye injection |
| post procedure IVP | hydrate to flush dye; monitor for allergic reaction if pt is sensitive; mucomyst for iodine clearance (po) |
| renal angiogram | uses contrast to evaluate renal & pelvic arteries primarily used to diagnose: RENAL ARTERY STENOSIS |
| ultrasound | masses |
| scopes | direct visualization; cytoscopy; nephroscopy |
| cystograms | check voiding patterns |
| cause of women UTI | shorter tract; intercourse; wet bathing suit; pantyhose |
| general risk factors for UTI | foley; DM due to bladder neuropathy; urinary retention |
| patho of UTI | gram negative bacteria: e-coli (80%) klebsiella; candidiasis; chlamydia; trichomonas; gonorrhea |
| older pt and UTI | may be asymptomatic except for mental status change |
| UTI subjective assessment | burning/pain on urination; frequency; urgency; abdominal pain/distention; N& D; fever; malaise |
| objective UTI assessment | + leukocyte estrase; + nitrates w/ urine dipstick; cloudy urine w/ mucous shreds; hematuria; urine culture;IVP; cystogram; cystoscopy |
| tx of UTI | antibiotics (usually bactrim); modify diet, cranberry juice, incr. fluid intake 3-4 L/day; |
| diet modifications for UTI | eliminate coffee; spicy foods; ETOH; chocolate; tomatoea |
| UTI teaching | no bath; no bubbles; no scented feminine hygiene products; wipe front to back |
| bladder cancer risk factors | SMOKING; exposure to dyes; asbestos; aromatic amines; artificial sweeteners; chronic cystitis; PID; highly treatable if tumor is superficial |
| most common sign of bladder cancer | painless hematuria |
| tx of bladder cancer | chemo (directly in bladder); radiation for advanced; urethral transection; partial cystectomy; radical cystectomy w/ urinary diversion |
| 2 ways to divert urine through surgical intervention | ileal conduit or indiana pouch (aka florida or kock pouch) |
| ileal conduit | part of the intestine is used to connect the ureters to a stoma; mucous shreds are normal; artificial pouch or bag is outside the body |
| indiana pouch | reservoir created by using ascending colon and terminal ileum; ureters are diverted to the pouch; connection to the abdomen; patient must self cath q 3-4 hrs |
| cause of urinary/renal calculi | renal stasis; calcium/oxalate/ uric acid/ or struvite stone formation |
| urinary/ renal calculi common in | men more than women; european & asian descent; southeast; northern ohio (stone belt) |
| what formes stones | urinary stasis; long hx of calculi; high mineral content drinking water; diet high in purines/oxalates/calcium supplements; animal proteins; UTI; foley;neurogenic bladder; female genital mutilation |
| subjective assessment of calculi | sharp pain; sudden/severe/low back/radiating pain; renal vs ureteral colic; N&V; sweating; anxiety; UTI w/ urinaty retention |
| objective assessment of calculi | hypertension; tachycardia; elevated temp; elevated WBC; pink urine; hematuria; |
| standard diagnostic test for calculi | KUB |
| tx of calculi | incr. fluids 3-4 L/day; narcotics; antispasmodics; dietary changes; lithotripsy; meds |
| dietary changes for calculi | decrease calcium w/ oxalate; decrease tea; tomatoes; colas; rhubarb; chocolate; citrus; w/ uric acid low prunes; no aged cheese; wine; bony fish; organ meat |
| meds for calculi | calcium thiazide diuretics; calcium oxalte STONES: vit. B, mag oxide, cholestyramine, allopurinol, URIC ACID STONE: allopurinal |
| before calling the doc for low urine output | assess for distension, irrigate foley, possibly change foley |
| diabetic nephropathy leads to | renal failure |
| IDDM or NIDDM & kidneys | nephrons are destroyed; glomerulus scars leading to renal insufficiency |
| the best indicators for assessing for nephropathy | microalbuminuria |
| when pt starts spilling protein | they are more likely to go into renal failure in 5-10 yrs |
| rhabdomyolysis | myoglobin released- toxic to renal tubules causes urine to have brown color |
| how to assessrhabdomyolysis | draw serum myoglobins |
| cause of rhabdomyolysis | traumatic skeletal muscle trauma; strenuous exercise; seizure; heat stroke; prolonged coma; can lead to acute or chronic renal failure |
| tx of rhadomyolysis | initially fluids to flush myoglobins |
| tx if kidney fails in rhadomyolysis | dialysis; monitor e-lytes; fluid balance |
| pyelonephritis | bacterial infection of renal pelvis and parenchyma |
| causes of pyelonephritis | bladder infections; e.coli is the most common culprit |
| acute pyelonephritis | bacterial contamination |
| chronic pyelonephritis | occurs after chronic obstruction w/ reflux or chronic disorders |
| assessment of pyelonephritis | subjective and objective similar to cystitis, sometimes w/ more back pain |
| most common type of renal cancer | adenocarcimoma |
| links to renal cancer | relatively unknown causes; tobacco; genetics;lead;cadmium; & phosphates suspected |
| assessment of renal cancer | gross hematuria; flank pain; palpable adominal or flank mass |
| tx of renal cancer | radiation; chemo; surgery (nephrectomy) |
| stress incontinence | occurs as a result of increased intra abdominal pressure; sneezing;laughing; post obstetric & beyond |
| urge incontinence | involuntary urination w/ little warning; gotta go; post menopause; MS; parkinson's |
| overflow incontinence | involuntary loss associated w/ bladder distention- BPH; narcotics; antihistamines; ETOH |
| tx of urinary incontinence | kegel exercises; bladder training; regulation of fluid intake; (TENS) electrical stimulation; meds: anticholinergic (ditropan) |
| BPH risk factors | poorly understood |
| BPH prevelance | increases in men as they age |
| sx of BPH | difficulty starting; stopping urine; incontinence; retention UTI |
| BPH screening | PSA anually at age 50 and DRE every year for men w/ at least 10 year life expectancy |
| normal PSA | < 4.0 ng/dl |
| meastatic rate of prostate cancer | slow |
| BPH meds | flomax; proscar |
| glomerulonephritis | immune reaction that causes inflamm & scarring in the glomerulus (lupus; allergic reactions; sickle cell) |
| glomerulus | the functional unit of filtration |
| glomerulonephritis diagnosis | percutaneous renal biopsy |
| nephrotic syndrome | protein wasting due to glomerular damage |
| objective assessment of nephrotic syndrome | proteinuria; hypoalbuminemia; edema |
| patho of nephrotic syndrome | loss of protein in vascular space causes plasma to leak out into interstital space; low intravascular volume stimulates RAA system causing sodium & water retention= massive edema |
| tx of nephrotic syndrome | maintain fluid & e-lyte imbalance; reduce inflamm w/ steroids; prevent thrombosis; minimize protein loss |
| nephrotic syndrome e-lyte imbalance | diuretics; albumin; increased risk for skin breakdown due to cellurlar edema |
| nephritic syndrome | hematuria; oliguria (< 400 ml urine/24 hrs); hypertension |
| why is there NO edema in nephritic syndrome | protein is not spilled in the urine; protein helps to maintain oncotic pressure in the vascular system |
| polycystic kidney disease | hereditary disorder; cysts on kidneys filled w/ serous fluid or blood |
| risk for polycystic kidney disease | 10% transplant pt.; hemodialysis pt of PCD; age 40-80 |
| patho of polycystic kidney disease | kidneys enlarge w/ cysts and put pressure on other organs eventually causing nephron destruction causing renal failure |
| signs & sx of polycystic kidney disease | lumbar/flank pain; hematuria; uremia; proteinuria; palapable masses; pyuria |
| tx of polycystic kidney disease | no cure; dialysis or transplant |
| acute renal failure AKA | uremia/uremic sydrome = urine in the blood |
| mortality rate of acute renal failure | 50% esp. after surgery or trauma |
| acute renal failure patho | initially urinary output adequate; but toxins not well filtered abrupt loss of function over hrs or days |
| acute renal failure oliguria | defined as 100- 400 cc/day |
| objective assessment of acute renal failure | increased BUN/creatinine/decreased output |
| how much do adults need to urinate per day | 400 cc/day to secrete enough waste products |
| prerenal ARF | anything that impairs renal perfusion; shock; volume shifts; dec. cardiac output; vascular obstruction; hypotension; hypovolemia |
| intarenal ARF | damage to the renal tubules from nephrotoxic agents; glomerulonephritis; rhabdo |
| post-renal ARF | obstruction of the urinary tract; enlarged prostate; stones; tumors |
| non-oliguric ARF | urine is dilute; filtering is not done, but fluid loss can be great; so BUN/ Creatinineare elevated BUT hypokalemia is a risk |
| oliguric ARF | (100-400 cc urine/day)- higher morbidity & mortality; mimics; CRF in terms of e-lyte imbalance; fluid volume overload |
| tx of ARF | maintain fluid & e-lytes; I&O; wt. ecg. acid-base balance; dialysis; prevent secondary infection; maintain nutrition (high cal. low protein |
| leading cause of death in ARF | secondary infection |
| ARF early phase meds | diuretics ( only help in early phase) |
| meds for ARF | sodium bicarb ( metabolic acidosis) kaexylate (hyperkalemia) insulin; antihypertensives; antibiotics (avoid nephrotic agents) |
| insulins for ARF | regular insulin IV push along w/ 50% dextrose insulin to drive K+ into cells; dextrose to prevent hypoglycemia |
| ARF & dialysis | temporary cath if tolerated otherwise renal replacement therapy = continuous venous-venous hemodialysis; continuous arterio-venous dialysis |
| continuous venous-venous hemodyalisis | blood drained from one venous port filtered in machine and returned through another venous port continuously 24/7; most common; pt needs systolic pressure of 80 or system clots off |
| continuous arterio-venous hemodialysis | artery & vein used to drain & return pt needs systolic pressure of 90 or will clot off |
| leading causes of chronic renal failure | DM & hypertension; ARF; nephrotoxins; glomerulonephritis |
| objective assessment of CRF | azotemia = elevated BUN/creatinine; urine in blood |
| reduced renal reserve | BUN is high- normal but no clinical manifestations of renal failure |
| renal insufficiency | mildly elevated BUN/creatinine, mildly anemic, renal function affected by stress |
| renal failure-acidosis | severe anemia, e-lyte imbalances impaired urine dilution |
| ESRD end-stage renal disease | kidnes are totally shut down and contribute nothing t homeostasis |
| CRF e-lyte imbalance | sodium retention; hyperkalemia; hypocalcemia; hyperphosphatemia; lower phosphate with Renegal |
| CRF metabolic changes | impaired insulin production/metabolism; elevated triglycerides; metabolic acidosis |
| CRF hematologic changes | anemia (decreased erythropoetin) |
| CRF GI changes | N/V; bitter metalic or salty taste; increased sectetion of gastrin (more acid = more ulcers) |
| CRF immune system change | decreased function = more infections; decreased lymphocyte action |
| CRF system changes | osteomelacia; changes in med metabolism; pulmonary edema |
| CRF cardio vascular changes | volume overload; hypertension; stimulation of RAAS |
| CRF skin changes | dry due to atrophy of sweat glands; pruritis; pupura; petechiae; bruising; pallor; grayness due to pigment changes; brittle hair & nails |
| CRF reproductive changes | menstrual irregularities; pregnancy is still possible; low sperm counts |
| CRF psychosocial changes | stress; powerlessness; body image changes; role strain; financial strain |
| CRF medical management | preserve renal function; epogen/procrit med; phosphate binding agents; supplemental iron; dialysis; transplant |
| how to preserve renal function w/ CRF | control blood pressure; reduce protein intake |
| purpose of epogen/procrit meds for CRF | stimulates rbc production by bone marrow |
| purpose of phosphate binding agents for CRF | (Renegal): high PO4 causes low CA; these drugs bind phosphate (calcium & phosphate have and inverse relationship) |
| peritoneal dialysis | instilled via a cath into peritoneum; allowing e-lyte exchange while retained (dwell time) then removed; waste removed through outflow; CRF & ARF no machines/electricity; insulin can be added to the dialysate |
| contradictions to peritoneal dialysis | scarring or adhesions in the peritoneal cavity; obesity; failure of PD to clear toxins; abdominal malignancies; extensive abdom surgeries; peritonitis |
| CAPD continuous ambulatory peritoneal dialysis | four dialysis cycles every 24 hrs w/ 8 hr dwell overnight |
| how peritoneal dialysis works | warmed dialysate is placed by gravity; usualy 2L; prevent air from entering; fluid runs out by gravity |
| peritoneal dialysis dwell times during the day | 30 - 45 min; maximum exchange occurs in the first five min. |
| peritonitis complications of peritoneal dialysis | fever; rebound abd. tenderness; elevated WBC |
| prevention & tx of peritonitis | prevent w/ aseptic technique; tx w/ antibiotics oral or in dialysate |
| peritoneal dialysis catheter complications | kinking/ obstruction |
| peritoneal dialysis bowel perforation complications | fecal material in the dialysate |
| dialysate proplems | too rapid infusion of dialysate (slow down instillation); hypotension due to rapid removal; hyperglycemia |
| uses for hemodialysis | ARF & CRF |
| hemodialysis | blood is cleaned using a pump and dialysate fluid to draw out waste |
| how hemodialysis works | arterial blood is cleaned first and then the blood is returned to the venous side |
| hemodialysis tx times | 3 - 4 hours of treatment 3 days a week |
| pt hemodialysis wt. loss | prescribed by md; goal according to the pts dry weight |
| who does the dialysis | dialysis tech or nurse |
| preffered HD access devise | intrnal arteriovenous fistula |
| internal arteriovenous fistula | surgical procedure where artery in the arm is anastomosed to a vein in the arm (takes 6 weeks to mature) |
| artificial AV fistula w/ Gore-Tex graft or bovine arteries | used for pts who don't have adequate blood vessels or who have lost previous natural grafts (takes 2 weeks to mature) |
| nursing must w/ HD access devices | must be assessed daily for a bruit and a thrill |
| complications of HD | clotting; infection; aneurysms of the graft; hypo/hypertension; dysrhythmias r/t e-lyte imbal.; air embolus; hemorrhage; infection- hep B; endocarditis |
| technical problems w/ HD | leaks; improper dialysate solution |
| dialysis disequlibrium syndrome | esp. during 1st few days of dialysis; mental confusion; dec.LOC; headache; seizure; may last several days - new pts will have slower flow rates and shorter times |
| CRF and diet | decreased protein; N/V; anorexia; dietary consult |
| protein intake for HD pt | 1.2 g per day |
| protein intake for PD pt | 1.3 g per day |
| types of burns | thermal; chemical; electrical (40 - 1000 volts enty/exit wound); radiation (leat common); inhalation |
| patho of inhalation burns | smoke causes chemical damage to the lungs; decreased surfactant; local inflammation = ARDs |
| degree of burn injury | partial or full thickness |
| first degree burn | partial thickness; superficial; red |
| second degree burn | partial-thickness; blister; heals 3 - 7 days; sunburn |
| third degree burn | full thickness; damage throughout the dermis; dry; black; brown;charred appearance; needs surgical debridement & skin graft |
| fouth degree burn | skin; fat;muscle; and bone; extensive debridement; grafting & amputation |
| when to expect systemic affects with burns | 25% surface area damaged |
| burn fluid shifts | hypovolemic shock |
| burn effects w/ pulmonary system | affected by shock state worsened if inhalation injury |
| burns and myocardial | HR increases; BP decreases & CO falls |
| immunosuppression & burns | decreased lymphocyte activity |
| fluid & e-lyte imbalance w/ burn | hypo/hypernatremia; hyperkalemia |
| burn background pain response | constant pain felt at rest of non-procedure activities |
| burn procedural pain | felt during dressing changes or wound debridement: high intensity |
| burn rule of nines | head 9% ; anterior thorax 18% ; posterior thorax 18% ; each arm 9% ; each leg 9% ; pubic area 1% |
| burn fluid resuscitation | required for 15% surface area injury; large bore IV; central line; cut-downs; LR in 1st 24 hrs based on wt.; colloids added w/ dextrose second 24 hrs |
| how to stop burning | cooling; wet down; remove smoldering clothing; irrigate chemical burns |
| who should go to a burn center | any third degree burn |
| wound care | cover w/ clean towel until transfered to burn center; cleanse; debride; topical agents;dressings; eschar removal daily; hydrotherapy; (all done daily) |
Created by:
aclelan
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