Test review NR325 Med-Surg II

Test review NR325 Med-Surg II 

Diabetes Mellitus- high levels of glucose resulting from defects in insulin secretion

Compare Type 1 and Type 2  
    

Clinical manifestations

Ø  Type 1- insulin dependent; pancreas does not function

·         Polyuria- frequent urination

·         Polydipsia- excessive thirst

·         Polyphagia – excessive hunger

·         Weight loss may occur because the body cannot get glucose and turns to another energy source such as fat and protein.

Ø  Type 2- inadequate insulin production/body has lack of sensitivity

·         Fatigue

·         Recurrent infections

·         Recurrent vaginal yeast or candidal infections

·         Prolonged wound healing

·         Visual changes

·         The clinical manifestations of type 2 DM are often nonspecific

Ø  What is lab test(s) used to diagnose?

·         A1C of 6.5%or higher

·         Fasting plasma glucose (FPG) greater than or equal to 126 mg/dL

·         Two-hour plasma glucose level greater than or equal to 200 mg/dL

·         Random glucose greater than or equal to 200 mg/dL

Ø  Indicators of good control?

·         HBA1C- checks blood glucose for the last 3mo (90-120 days)

Ø  Insulin: 

·         Rapid (clear) - has an onset of action of approximately 15 minutes and should be given within 15 minutes of meal times; peak 60-90 min

§  Lispro (Humalog)

§  Aspart (Novolog)

§  Glulisine (Apidra)

·         Short (clear) - has an onset of action 30-60 minutes and should be injected 30 to 45 mins before a meal to ensure that the onset of action coincides with meal absorption.

§  Regular insulin (Humulin R, Novolin R)  peak 2-3hrs

·         Intermediate (cloudy)- only basal insulin that can be mixed with short and rapid-acting insulin.

§  NPH, Humulin N, Novolin N  Onset: 2-4hrs  Peak: 4-10hr

·         Long-acting (clear)- is released  steadily/continuously and used once daily SubQ; Onset: 1-2hr   NO PEAK OF ACTION; CANNOT BE MIXED

§  Glargine (Lantus)

§  Detemir (Levemir)

Gestational diabetes: what are the concerns?

·         Women with gestational diabetes have a higher risk for cesarean delivery, and their babies have increased the risk for perinatal death, birth injury, and neonatal complications. Women who are at higher risk for gestational diabetes should be screened at the first prenatal visit. Those at high risk include women who are obese, advanced age, glycosuria, dx of polycystic ovary syndrome or have a family history of diabetes.

·         Oral glucose tolerance test (OGTT) performed at 24-28 wks of pregnancy 

DKA versus HHS and plan of care

Ø  DKA (Diabetic ketoacidosis)- diabetic coma; deficiency of insulin;

·         Is an acute complication of type 1 diabetes

·         Body is in a battle with insulin

·         The cells do not like insulin

·         Cells will not let insulin in

·         Because the cells will not let insulin in, the blood becomes concentrated with glucose. Without insulin in the cells glucose cannot enter the cells as well

·         No glucose = No energy

·         Body will use proteins instead of glucose for energy

·         The protein will break down into ketones and ammonia

·         Clinical Manifestation: Tachycardia, orthostatic hypotension, dry mouth, thirst, abdominal pain, N/V, confusion, lethargy, flushed dry skin, sunken eyes, fruity breath odor of acetone, Kussmaul breathing, urinary frequency, fever, ketonuria, serum glucose >250

·         Interventions: IV fluids/electrolytes until BP stabilized and urine output is 30-60ml/hr. Administer IV of short-acting insulin

§  Record I &Os

§  Assess mental status, bs levels, urine for ketones, cardio/resp status

Ø  HHS(Hyperosmolar hyperglycemic syndrome) - the body produces insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic dieresis, &extracellular fluid depletion. (Requires greater Fluid replacement than DKA)

·         Acute complication of type 2 diabetes

·         Blood sugars over 600

·         High fevers

·         Increase thirst because body is trying to dilute extra sugar in the body

·         Increased urination to get rid of extra sugar in the body

·         Lack of perfusion

·         Body will try to burn and get rid of extra sugar

·         Clinical manifestations: symptoms resemble stroke, somnolence, coma, seizures, hemiparesis, aphasia, change in mental status

·         Interventions: IV fluid replacement, IV insulin, monitors, potassium, and cardio. Assess vital signs, I &Os, tissue turgor, labs.

Thyroid Diseases

Compare hypo and hyperthyroidism

Assessment findings for hypo/hyper

Ø  Hyperthyroidism- hyperactivity of the thyroid gland

·         Increased heart rate

·         Increased B/P

·         Jitters

·         Always hot

·         Weight loss (must increase caloric intake)

Ø  Hypothyroidism- deficiency of thyroid hormones that cause a general slowing of the metabolic rate

·         Iodine deficiency is the most common cause

·         Fatigued/lethargic

·         Experiences personality and mental changes

·         Impaired memory

·         Slowed speech

·         Weight gain

·         Decreased cardiac contractility/cardiac output

·         SOB

·         Anemia

·         Bruise easily

·         Myxedema- facial puffiness, periorbital edema, and masklike affect

·         Administer Synthroid

Ø  Conditions of Hyperthyroidism

·         Graves Disease- #1 cause of hyperthyroidism

§  Autoimmune disease

§  Patients develop antibodies to the TSH receptors

§  Antibodies attach to the receptor and stimulate thyroid gland to release T3 and T4

§  Exophthalmos (big/protruding eyes)

Ø  Nursing interventions post Thyroidectomy

·         Respiration may also become difficult because of excess swelling of the neck tissues, hemorrhage, and hematoma formation

·         Assess the patient q2hrs for 24 hrs for signs of hemorrhage or tracheal compressions such as irregular breathing, neck swelling, frequent swallowing, and sensations of fullness at the incision site, choking, and blood on the anterior or posterior dressing.

·         Place patient in a semi-fowlers position and support the patients head with pillows. Avoid flexion of the neck and any tension on the suture lines

·         Monitor vital signs and calcium levels

·         Check for signs of tetany (tingling, in toes, fingers, around mouth, muscular twitching, apprehension)

·         Evaluate difficulty in speaking and hoarseness

·         Monitor Trousseau’s sign and Chvostek’s sign

·         Expect some hoarseness for 3 or 4 days after surgery because of edema

·         To prevent weight gain caloric intake must be reduced substantially below the amount that was required before surgery

·         Adequate iodine is necessary to promote thyroid function

·         Seafood once or twice a week or normal use of iodized salt should provide sufficient iodine intake

·         Teach patient to avoid high environmental temperatures

·         Tracheostomy kit at the bedside as well as suctioning and O2

·         Calcium gluconate

·         Administer Synthroid; lifelong thyroid replacement

Assessment of client in Thyrotoxic crisis

·         Is an acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation

·         Severe tachycardia

·         Heart failure

·         Shock

·         Hyperthermia (up to105.3F)

·         Restlessness/irritability

·         Delirium

·         seizures

·         abdominal pain

·         vomiting

·         diarrhea

Adrenal Diseases

Assessment of client with Cushing’s syndrome

·         Excess of corticosteroids

·         Corticosteroids response to stress (cortisol is a stress hormone that makes you gain weight)

·         Cortisol decreases inflammation but too much will cause:

·         Truncal obesity

·         Buffalo Hump

·         Purple striae

·         Hirsutism and menstrual disorders in females

·         Gynecomastia in males

·         Moon face

·         HTN

·         Unexplained hypokalemia

Post op Adrenalectomy priority nursing care

·         Risk of hemorrhage

·         Fluid and electrolyte imbalance

·         Monitor I&Os

·         Stabilize BP

·         Risk for infection, check wound drainage

·         Home care: Wear medic alert bracelet, avoid extreme temps, inf, emotional disturbances, adjust corticoidsteroids according to their stress levels.

Pituitary Diseases    pg 1256

Compare SIADH and Diabetes Insipidus

Ø  SIADH (Syndrome of inappropriate antidiuretic hormone)

·         Overproduction or oversecretion of ADH (antidiuretic hormone)

·         More common in older adults

Ø  S/S

·         Fluid retention

·         Serum hyperosmolality

·         Dilutional hyponatremia- muscle cramps, pain, weakness

·         Hypochloremia

·         Concentrated urine in normal or ↑ intravascular volume

·         Normal renal function

·         Thirst

·         Dyspnea on exertion

·         Fatigue

·         Low urinary output

·         Increased weight

·         Seizures

·         Vomiting

Ø  Interventions for SIADH

·         Vital signs monitor heart and lungs sounds

·         Measure I & Os

·         Measure specific gravity of urine

·         Daily weights

·         Assess level of consciousness

·         Observe signs form hyponatremia

·         Restrict fluid intake to 1000mL/day

·         Lay HOB flat or 10 degrees elevation

·         Protect from injury

·         Seizure precaution

·         Frequent turning, positioning, and ROM exercise

·         Frequent oral hygiene

·         Provide distraction to ↓ discomfort of thirst r/t fluid restriction

·         Provide support

Ø  Diabetes Insipidus

o   Underproduction or undersecretion of ADH (antidiuretic hormone)

o   Types of DI

§  Central DI- interference with ADH synthesis or release; brain tumor, head injury, brain surgery

§  Nephrogenic DI – inadequate renal response to ADH;  renal damage

§  Primary DI- excessive water intake; lesion in thirst center

o   S/S – polydipsia, polyuria, excretion of large quantities of urine w/ low specific gravity and urine osmolality <  100mOsm/kg. severe fluid volume loss, wt loss, constipation, poor skin turgor, hypotension, tachycardia, shock, irritability, mental dullness, coma.

o   Interventions

§  fluid and hormone replacement; orally or IV

§  the record I & Os, urine specific gravity, daily weights

§  LOW SODIUM DIET! Limit sodium < 3 g/day

§  monitor glucose level

Ø  Assessment of a client with Acromegaly

o   Excessive growth hormone in adults caused by benign pituitary tumor

§  Assess for abnormal tissue growth, changes in physical size

§  Question about ↑ in hat, ring, glove, and shoe size

§  Use photos to evaluate changes

Ø  S/S Acromegaly

o   Enlargement of hand and feet w/ joint pain

o   Changes in physical appearance

o   thickening of bones and soft tissues on face and head

o   enlargement of the tongue; speech difficulties, voice deepens

o   sleep apnea

o   skin is thick, leathery, oily

o   peripheral neuropathy

o   proximal muscle weakness

o   menstrual disturbance

o   visual disturbance

o   headaches

o   hyperglycemia

Ø  Interventions for Acromegaly/Nursing interventions for client pre and post-op resection of pituitary tumor

o   Tx; surgery- transsphenoidal hypophysectomy

o   Post op- Elevate HOB @ 30-degree angle at all times

o   Avoid vigorous coughing, sneezing, straining stool (Valsalva maneuver)

o   Send any clear nasal drainage to lab to check for glucose; may be CSF leakage

o   Give mild analgesics

o   Mouth care every 4 hrs

o   Avoid brushing teeth for 10 days

o   Monitor v/s, neurologic status, fluid volume status

o   Pin site care

o   No straws

o   Monitor urine output, urine osmolarity

o   Possible post-op complication is Diabetic Insipudus (DI)

o   Hormone replacement therapy

Urinary incontinence & Urinary tract infection    pg 1122 & 1148

Urinary Incontinence: Uncontrolled leakage of urine

·         Types of urinary incontinence

o   Stress – coughing, laughing, sneezing, exercise

o   Urge- urgency; overactive bladder

o   Overflow- overfull bladder overcomes sphincter control

o   Reflex- stress

o   After trauma or surgery

o   Functional- elderly; cognitive, functional, environmental factors

·         Patient teaching for Urinary incontinence pg. 1149, table 46-19

o   Consumption of adequate volume of fluids

o   Reduction/elimination of bladder irritants such as caffeine, alcohol

o   Maintain a regular, flexible schedule of urination every 2-3 hrs while awake

o   Quit smoking (smoking increases the risk of stress UI)

o   Aggressive management of constipation, ensure adequate fluid intake, increasing dietary fiber, light exercise, judicious use of stool softeners

o   Voiding regimens (timed voiding, habit training, prompted voiding), bladder retraining, pelvic floor muscle training

o   Prevent soiling of clothing

o   Use of assistive devices: toilet seats, bedside commode, urinal/bedpan as needed

o   Use incontinence pads or incontinence protective underwear

Intravenous pyelogram (IVP) and nursing care pg. 1115 table 45-8

Ø  IVP- Visualizes urinary tract after IV injection of contrast media.

o   Position, size, and shape can be evaluated

Ø  Nursing care

o   Evening before procedure give enema

o   Assess for allergies to contrast dye, iodine, shellfish.

o   Procedure involves pt lying down and having serial x-rays taken

o   Warmth, flushed face, and salty taste may occur

o   After procedure, force fluids to flush out contrast dye

Teaching proper hygiene to urinary area pg. 1127, table 46-6

·         Cleanse perineal region by separating the labia

·         Wipe front to back

·         Cleanse with warm soapy water after each bowel movement

·         Empty bladder before and after sexual intercourse

·         Urinate regularly

·         Avoid vaginal douches, hard soaps, bubble baths, powders, sprays in perineal area

Urinary Catheter Care pg. 1153

·         Sterile closed drainage system should be used for short-term catheterization

·         Bag should be emptied when it reaches 400 mL and kept below bladder

·         Perineal care w/ soap and water 1-2 times a day or as necessary

·         Do not use lotion or powder near catheter

·         Catheter should be anchored

o   Women- upper thigh

o   Men- lower abdomen

·         Use sterile 21 gauge needle to culture urine; clean puncture site with iodine or alcohol 1st

·         If pt is catheterized for < 2wks; no catheter change

·         Long-term catheter should be changed according to pt assessment

·         Leg bag may be used for long-term catheter

o   If bag is reused wash w/ soap and water

o   If not used immediately, fill bag w/ ½ cup of vinegar and drain

·         Remove catheter at earliest moment possible

Clinical manifestations of UTI       pg. 1124, table 46-3

v  UTI- Infection or inflammation at any site in the urinary tract

Ø  Patho:

·         The entire urinary tract is sterile. The most common infectious agent is E.coli.

o   Kidney- Pyelonephritis,

o   Urethra- Urethritis,

o   Bladder - Cystitis,

o   Prostate- Prostatitis)

Ø  S/S of UTI:

·         fever and chills

·         Urinary frequency, urgency, or dysuria

·         Hematuria, sediment, cloudy appearance

·         Suprapubic discomfort, flank pain

·         Elevated serum WBC > 10,000

·         Older adults: nonlocalized abdominal discomfort, cognitive impairment

Ø  Nursing Intervention:

·         Administer antibiotics

·         Maintain I&O

·         Administer mild analgesics

·         Proper medication regimen

·         Encourage fluid intake of 3000mL of fluids/ day

·         Encourage client to void every 2-3 hrs to prevent residual urine from staying in the bladder

Ø  Teaching:

·         Take entire prescription as directed

·         Consume oral fluids up to 3L/ day ( water or juice)

·         Shower rather than bathe. If bathing is necessary, never take a bubble or oil bath and avoid feminine hygiene sprays

·         Clean from front to back

·         Avoid caffeine

·         Void immediately after sex

·         Void every 2-3 hours during the day

·         Wear cotton underwear and lose clothing to decrease perianal moisture

·         Good hand washing technique

·         Obtain follow-up care

Understand urinalysis and UA with C&S – pg. 1119 table 45-9, pg. 1114 table 45-8, pg. 1124 on the right next to table 46-3

Ø  Urinalysis- general exam of urine. It’s best to obtain the first specimen in the morning and should be examined within 1hr of urination if not possible refrigerate specimen.

Ø  Urine culture- confirms UTI and identifies the causative organism.

o   Collect urine in sterile container; touch only outside of it

o   Women- separate labia with one hand and clean meatus with another hand, using 3 sponges with a cleansing solution in a front to back motion.

o   Men- retract the foreskin and cleanse glans with 3 cleansing sponges. After cleaning, start urinating in the toilet and then continue to voiding in a sterile container.

Renal calculi-Kidney Stones

Ø  Renal calculi -Crystals, when in a supersaturated concentration, can precipitate and unite to form a stone.

Ø  Types of calculi – pg. 1137, table 46-12

·         Calcium oxalate- small stone trapped in ureter; common in men; r/t hypercalciuria, family hx

·         Calcium phosphate- mixed with struvite or oxalate stone r/t hyperparathyroidism

·         Struvite- large staghorn type, common in women r/t UTI

·         Uric acid- common in Jewish men r/t gout

·         Cystine- genetic autosomal recessive defect; defect absorption of cystine in GI/kidney r/t acid urine

Ø  Nursing care for Renal calculi

·         Relief of pain, no urinary tract obstruction, knowledge of ways to prevent further recurrence of stones

·         Fluid intake to produce a urine output of 2 L/ day

·         Encourage pt to drink about 2000 to 2200 mL/dayw/ residual 20% - 30% of fluids gained through consumption of foods

·         Bed rest pt: maintain an adequate fluid intake, turn every 2 hrs, helps pt sit or stand if possible to maximize urinary flow

·         Diet restriction of purines for pt at risk for developing uric acid stones

·         Reduced intake of oxalates for pt w/ recurring calcium oxalate calculi

·         Teach pt the dosage, scheduling, & potential side effects of drugs used to reduce the risk of stone formation

·         Teach pt to self-monitor urinary pH

·         Provide pain relief measure

·         All urine voided by the pt should be strained through gauze/ urine strainer

·         Ambulation is generally encouraged to promote movement of the stone from the upper to the lower urinary tract

Ø  Clinical manifestations of Renal calculi

·         Severe pain that is sudden

·         Sharp pain in flank area, back or lower abdomen

·         Renal colic (sharp pain from stretching or ureter in response to stone obstruction)

·         Nausea and vomiting (bc of severe pain)

·         No pain (if stone does not obstruct)

·         Constant movement of patient from sitting to standing, vice versa due to pain

·         Pain depends on location of stone

·         Hematuria

·         UTI with fever and chills

·         Mild shock with cool moist skin

·         Men may experience testicular pain

·         Women may experience labial pain

Ø  Risk Factors for Renal calculi

·         Metabolic

§  Abnormalities that result in increased urine levels of calcium, oxaluric acid, uric acid, or citric acid

·         Climate

§  Warm client that causes increased fluid loss, low urine volume, and increased solute concentration in urine

·         Diet

§  Low sodium diet

§  Restrict purines

DO NOT!!!!!!

-          Large intake of protein that increases uric acid excretion

-          Excessive amounts of tea and juices that elevate urinary oxalate levels

-          Large intake of calcium and oxalate (milk, cheese, spinach)

-          Low fluid intake that decreased urinary concentration

·         Genetic factors

§  Family history

§  Lifestyle

§  Sedentary occupation, immobility

·         Diagnostics renal calculi

o   Noncontrast CT scan

o   Urinalysis

o   Serum calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, BUN, and creatinine levels

·         Interventions for renal calculi

o   Strain all voided urine until stone passes

o   Have patient increase fluids

o   Manage pain

o   Have patient sit or stand to maximize urinary flow

·         Treatment renal calculi

o   Opioids for pain

o   Adrenergic blockers to relax muscles

·         Patient teaching renal calculi

o   Encourage patient to drink lots of fluid

o   Proper diet, pg. 1139, table 46-13 for nutritional therapy

o   Maintain activity at level that will prevent urinary stasis & resorption of calcium from bone

o   Observe amount & character of urine & report to health care provider at f/u visit

o   Report increased pain, persistent blood in urine, inability to void, significant decrease in urinary output

o   Report signs of infection, burning w/ urination, cloudy urine, or fever

Assessment findings Post Lithotripsy – pg. 1138(Lithotripsy- a procedure used to eliminate calculi from the urinary tract.)

·         Hematuria – the first few times, urine is bright red, as the bleeding subsides, the urine becomes dark red or turns a smoky color

·         Complains of moderate to severe colicky pain

·         Antibiotics administer for 2 wks to reduce the risk of infection

·         Self-retaining ureteral stent to facilitate passage of sand & prevent sand buildup w/in the ureter removed w/in 2 Wks

Renal carcinoma (Kidney Cancer) – pg. 1144

·         Arise from the cortex or pelvis (and calyces).

·         Adenocarcinoma is the most common

·         Occurs more often in men. Ages: 50-70

·         Definitive test for kidney cancer: CT scan

Clinical manifestations of Renal Carcinoma (Kidney cancer)

·         Renal carcinoma: Hematuria, flank pain, palpable mass in the flank /abdomen, weight loss, fever, HTN, anemia, UTI: frequency, dysuria, urgency

Risk factors for Renal Carcinoma (Kidney Cancer)– pg. 1144

·         Cigarette smoking is most significant risk factor

·         Obesity

·         HTN

·         Exposure to asbestos, cadmium, and gasoline

·         Cystic disease of kidney

·         End Stage Renal Disease (ESRD)

Acute Kidney Failure = Acute kidney injury (AKI)pg. 1165

Ø  Acute kidney failure

·         Occurs when metabolites accumulate in the body and urinary output changes

·         AKI can develop over hours or days with progressive elevations of blood urea nitrogen (BUN), creatinine, and potassium with or without a reduction in urine output

·         Three phases of alterations in urinary output:

o   Oliguric phase- reduction of urine output < 400mL/day; occurs 1-7 days of injury

o   Diuretic phase- High volume of urine output 3-5 L or more/day

o   Recovery phase- Everything goes back to normal

Ø  S/S

·         Hypovolemia

·         Metabolic Acidosis

·         Hypernatremia

·         Hyperkalemia

·         Hematologic disorders

§  Leukocytosis

·         Waste product accumulation

·         Edema

·         Weight gain (ask if waistbands have suddenly become too tight)

·         Change in mental status

Ø  Risk Factors  Acute kidney failure

Prerenal (factors outside of the kidneys)

Ø  Hypovolemia

o   Dehydration

o   Hemorrhage

o   GI losses (diarrhea, vomiting)

o   Excessive diuresis

o   Hypoalbuminemia

o   Burns

Ø  Decreased Cardiac Output

o   Cardiac dysrhythmias

o   Cardiogenic shock

o   Heart failure

o   Myocardial infarction

Ø  Decreased Peripheral Vascular Resistance

o   Anaphylaxis

o   Neurologic injury

o   Septic shock

Ø  Decreased Renovascular Blood Flow

o   Bilateral renal vein thrombosis

o   Embolism

o   Hepatorenal syndrome

o   Renal artery thrombosis

Intrarenal (cause direct damage to the kidneys)

Ø  Nephrotoxic Injury

o   Drugs: aminoglycosides, amphotericin B

o   Contrast media

o   Hemolytic blood transfusion reaction

o   Severe crush injury

o   Chemical exposure: ethylene glycol, lead, arsenic, carbon tetrachloride

Ø  Interstitial Nephritis

o   Allergies: antibiotics, NSAID, ACE inhibitors

o   Infections: bacterial (acute pyelonephritis), viral (CMV), fungal (candidiasis)

Ø  Other Causes

o   Prolonged prerenal ischemia

o   Acute glomerulonephritis

o   Thrombotic disorders

o   Toxemia of pregnancy

o   Malignant hypertension

o   Systemic lupus erythematosus

Postrenal (include obstruction of outflow of urine)

Ø  Benign prostatic hyperplasia

Ø  Bladder cancer

Ø  Calculi formation

Ø  Neuromuscular disorders

Ø  Prostate cancer

Ø  Spinal cord disease

Ø  Strictures

Ø  Trauma (back, pelvis, perineum)

Ø  Diagnostic:

·         History and physical examination

·         Identification of precipitating cause

·         Serum creatinine and BUN levels

·         Serum electrolytes

·         Urinalysis

·         Renal ultrasound

·         Renal Scan

·         CT scan

·         Oliguric phase

§  Increased BUN and Creatinine

§  Hyperkalemia

§  Hyponatremia

§  Acidosis

§  Hypervolemic

§  High urine specific gravity

·         Diuretic phase

§  Hypovolemia

§  Hypokalemia

§  Hyponatremia

§  Low urine specific gravity

·         Recovery phase

§  Lab work returns to normal range in this phase

Ø  Interventions Acute kidney failure

·         Monitor I & O, VS, fluid volume alterations

·         Assess Level of consciousness for subtle changes

·         Monitor lab values (serum and urine) to assess electrolytes (especially Hyperkalemia)

§  Monitor cardiac rate and rhythm (ECG)

·         Weigh daily: in oliguric phase

·         Diet: low protein, moderate fate, high carb; low sodium and  potassium

·         Assess and record extrarenal losses of fluid from vomiting, diarrhea, hemorrhage, and increased insensible losses.

·         Because infection is the leading cause of death in AKI, the meticulous aseptic technique is critical.

·         Perform skin care and take measures to prevent pressure ulcers because the patient usually develops edema and decreased muscle tone.

·         Mouth care is important to prevent stomatitis, which develops when ammonia (produced by bacterial breakdown of urea) in saliva irritates the mucous membranes.

Chronic Kidney Failure pg. 1171

Chronic Kidney Disease (CKD) - progressive, irreversible loss of kidney function, decreased GFR < 60 mL/min longer than 3 months, results in uremia (kidney function fail and affects multiple body systems.)

o   Dialysis is necessary, transplantation is an alternative

·         S/S

o   HTN

o   Pulmonary edema

o   Neurologic impairment (fatigue, headache, sleep disturbances)

o   Decreasing urinary function

§  Hematuria

§  Proteinuria

§  Cloudy urine

§  Oliguric (100-400mL/day)

§  Anuric (<100mL/day)

o   Jaundice, Pruritus, dry scaly skin

o   GI upsets

o   Metallic taste in mouth

o   Ammonia breathe

o   Waste product accumulation

o   CK failure affects every system

·         Risk factors

o   MAJOR CAUSE: Diabetes and HTN

o   Age >60 years old

o   Obesity

o   Cardiovascular disease

o   Family history

o   Exposure to nephrotoxic drugs

·         Diagnostics

o   History and physical examination

o   Identification of reversible kidney disease

o   Renal ultrasound

o   Renal Scan

o   CT scan

o   Renal biopsy

o   BUN, serum creatinine, and creatinine clearance levels

o   Serum electrolytes

o   Lipid profile

o   Protein-to-creatinine ratio in the first morning voided specimen

o   Urinalysis

o   Hematocrit and hemoglobin levels

·         Interventions  CKD

o   Monitor serum electrolyte levels

o   Weigh daily

o   Monitor strict I & O

o   Check for JVD and other signs of fluid overload

o   Diet: Low protein, low sodium, low potassium, low phosphate

·         Treatment

o   Correction of extracellular fluid volume overload or deficit

o   Calcium supplementation, phosphate binders, or both

o   Antihypertensive therapy

o   Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)

o   Measures to treat hyperlipidemia

o   Measures of lower potassium

o   Renal replacement therapy (dialysis, kidney transplant)

·         Teaching

o   Necessary dietary (protein, sodium, potassium, phosphate) and fluid restrictions.

o   Difficulties in modifying diet and fluid intake.

o   Signs and symptoms of electrolyte imbalance, especially high potassium.

o   Ways of reducing thirsts, such as sucking on ice cubes, lemon, or hard candy.

o   Rationales for prescribed drugs and common side effects. Examples: Phosphate binders (including calcium supplements used as phosphate barriers) should be taken with meals.

o   Calcium supplements prescribed to treat hypocalcemia directly should be taken on an empty stomach (but not at the same time as iron supplements).

o   Iron supplements should be taken between meals.

o   The importance of reporting any of the following: Weight gain >4 lb (2 kg)

§  Increasing BP

§  Shortness of breath

§  Edema

§  Increasing fatigue or weakness

§  Confusion or lethargy

o   Need for support and encouragement. Share concerns about lifestyle changes, living with a chronic illness, and decisions about the type of dialysis or transplantation.

o   Avoid certain over-the-counter drugs such as NSAIDs and aluminum- and magnesium-based laxatives and antacids

Types of dialysis – PD pg. 1182, look at table 47-13, HD pg. 1184 

Dialysis: is the movement of fluid & molecules across a semi-permeable membrane from one compartment to another

·         Begin dialysis when GFR is < 15 mL/min

Peritoneal dialysis (PD): remove toxins from blood of pt, uses peritoneal membrane (and) as semipermeable dialyzing membrane

o   Preparation: emptying the bladder and bowel, weighing the pt, obtaining a signed consent form

o   Check vital signs & weight

o   Warm dialysate to body temperature in a warmer

o   Teach pt to examine the catheter site for signs of infection

o   Exit site should not be submerged in bath water, showering is preferred

o   Hand washing is critical before exit site care

Hemodialysis (HD): a procedure to remove wastes from body by filtering blood using a machine; used primarily for clients w/ end-stage renal disease; may be used for emergency stabilization of pts such as life-threatening electrolyte levels/poisoning/overdose w/ substances not eliminated w/ gastric lavage/active charcoal

o   Red catheter lumen: closest to the fistula, used to pull blood from the pt & send it to the dialyzer w/ the assistance of a blood pump

o   Blue catheter lumen: the second needle, blood returned from the dialyzer to the pt

o   Preparation: Assessment of fluid status, weight, BP, peripheral edema, lung & heart sounds, condition of vascular access, temperature, general skin condition

o   The difference between the last post-dialysis weight and the present predialysis weight determines the ultrafiltration or the amount of weight to be removed

o   Take vital signs at least every 30 to 60 minutes

o   Use reclining chairs that allow for elevation of the feet if hypotension develops

o   Dialysis is continued for 3-4 hrs 3 days per week

Assessment of Access Sites – pg. 1185

Ø  Use for HD: need a very rapid blood flow; access to a large blood vessel is essential

·         3 Types:

1. Arteriovenous fistula (AVFs)

§  Created in the forearms w/ anastomosis between an artery & a vein (usually cephalic)

§  Best overall patency rates & least number of complications

§  Provides arterial blood flow through the vein

§  Increased pressure of the arterial blood flow through the vein makes the vein dilate & become tough, making it amenable to repeated venipuncture in 4-6 Wks

§  Placed at least 3 mo before the initiation of HD

2. Arteriovenous grafts (AVGs)

§  Made of synthetic material & form a bridge between the arterial & venous blood supplies

§  Placed under the skin & are surgically anastomosed between an artery (usually brachial) & a vein (usually antecubital)

§  2-4 wks to allow the graft to heal

§  More likely to become infected & a tendency to be thrombogenic

§  Large bore needles:14 – 16 gauge, inserted into the fistula/ graft to obtain vascular access

§  One needle is placed to pull blood from the circulation the HD machine, the other needle is used to return the dialyzed blood to the pt

§  Thrill can be felt by palpating the area of anastomosis

§  Bruit can be heard w/ a stethoscope (thrill & bruit are created by arterial blood rushing into the vein)

§  Never perform BP measurements, insertion of IV lines, & venipuncture in the extremity w/ the vascular access ( to prevent infection & clotting of the vascular access)

§  Risks: distal ischemia (steal syndrome) & pain due to too much of the arterial blood is being shunted or stolen from the distal extremity.

§  Steal syndrome: pain distal to the access site, numbness or tingling of fingers that may worsen during dialysis, poor capillary refill

3. Temporary &semipermanent catheters

§  Used for immediate vascular access, in the internal jugular/femoral vein

§  One lumen is used for blood removal & the other for blood return

§  Left in place for 1-3 wks, not to exceed 3 wks, femoral vein cannulas can remain    in place for up to 1 wks

Complications of dialysis

Ø  Peritoneal dialysis complications – pg. 1184

§  Exit site infection: caused by Staphylococcus aureus or S. epidermitis, resolved with antibiotic, s/s: redness at the site, tenderness, drainage

§  Peritonitis: result from contamination/ progression of an exit site or tunnel infection, s/s: cloudy peritoneal effluent w/ WBC > 100 cells/uL, abdominal pain, diarrhea, vomiting, abdominal distention, hyperactive bowel sounds, fever (use aseptic technique when handling catheter or tubing) this is critical to prevent because it could result in pt having to change therapy to hemodialysis

§  Hernias: due to increased intraabdominal pressure secondary to the dialysate infusion (use small dialysate volumes & keeping pt supine)

§  Lower back problems: due to increased intraabdominal pressure (use of orthopedic binders & a regular exercise program for strengthening the back muscles)

§  Bleeding: may indicate active intraperitoneal bleeding

§  Pulmonary complications: atelectasis, pneumonia, & bronchitis due to upward displacement of the diaphragm (frequent repositioning & deep breathing exercises, elevate the head of the bed to prevent these problems)

§  Protein loss: may result in malnutrition

§  Catheter obstruction from clots/ kinking (keeps all lines unobstructed, add heparin to dialysate per protocol)

§  Insufficient outflow (reposition pt as needed to bring fluid into contact w/ catheter, allow pt to ambulate if advisable due to condition)

§  Hypotension &hypovolemia from excess fluid removal (monitor I & O)

§  Hyperglycemia (from glucose in dialysate, monitor diabetic pt closely, no do not allow fluid to dwell longer than ordered)

§  Abd pain

Ø  Hemodialysis complications pg. 1187

§  Hypotension: result from rapid removal of vascular volume (hypovolemia), decreased cardiac output, decreased systemic intravascular resistance, s/s: light-headedness, n/v, seizures, vision changes, chest pain from cardiac ischemia, tx: decrease the volume of fluid being removed & infusion of 0/9% saline solution

§  Muscle cramps: due to hypotension, hypovolemia, high ultrafiltration rate, use of low-sodium dialysis solution, tx: reduce the ultrafiltration rate & administration of fluids (saline, glucose, Mannitol), hypertonic glucose administration is preferred, not hypertonic saline 

§  Loss of blood: result from blood not being completely rinsed from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture, or bleeding after the removal of needles at the end of dialysis

§  Hepatitis: recommended that all pts and personnel in dialysis units receive the hep B vaccine, infection control precautions for pt w/ hep C

§  Infection such as sepsis

§  Disequilibrium syndrome

§  Cardiovascular disease

§  Exsanguination

Kidney Transplant and Complications – pg. 1193, table 47-15

v  Need histocompatibility studies, human leukocyte antigen (HLA) testing & cross-matching

v  Lifetime immunosuppressant and steroids meds

Ø  Complications

§  Risk for infection

§  Rejection – low urine output/ fever

§  No kidney transplant if you have metastases cancer

Ø  Interventions

§  Fluid and electrolyte imbalance

§  After transplanting monitor urine output

§  Monitor renal function, hematocrit

Pyelonephritis pg. 1128, Table 46-7

·         Patho

o   is an inflammation of the renal parenchyma and collecting system (including the renal pelvis)

o   Usually begins with colonization and infection of the lower urinary tract via the ascending urethral route.

Ø  Clinical manifestationsPyelonephritis

o   Mild fatigue

o    Sudden onset of chills

o    Fever

o   Vomiting

o   Malaise

o    Flank pain

o    LUTS characteristic of cystitis including dysuria, urgency, and frequency

o   Cost vertebral tenderness to percussion

o   Bacteriuria

o   Pyuria

Ø  Risk FactorsPyelonephritis

o   E. coli or Proteus, Klebsiella, or Enterobacter species

o   A preexisting factor is often present such as vesicoureteral reflux (retrograde, or backward, movement of urine from lower to upper urinary tract) or dysfunction of the lower urinary tract (e.g., obstruction from benign prostatic hyperplasia [BPH], a stricture, a urinary stone).

o   For residents of long-term care facilities, urinary tract catheterization is a common cause

Ø  Diagnostics

o   Urinalysis

o   Urine for culture and sensitivity

o   Imaging studies: ultrasound (initially), CT scan, IVP, CT/IVP, VCUG, radionuclide imaging

o   CBC count with WBC differential

o   Blood culture (if bacteremia is suspected)

o   Percussion for flank (costovertebral angle [CVA]) pain

Ø  Intervention/ Implementations

o   Patient with severe symptoms require hospitalization

o   Patient with mild to moderate symptoms undergo outpatient antibiotics

o   Teach patient about the disease process with emphasis on continuing medications as prescribed

o   Follow-up urine culture and image studies

o   Recognizing manifestations of recurrence or relapse

o   Encourage the patient to drink at least 8 glasses of fluid daily, even after the infection has been treated.

o   NSAID or antipyretic drugs to reverse fever & relieve discomfort

o   Maintain bed rest until symptoms subside

Urinary diversion Ch. 46, pg. 1155

Ø  Patho

o   Surgery to bypass urethra and bladder

o   Procedures  performed to treat cancer of the bladder, neurogenic bladder, congenital anomalies, strictures, trauma to the bladder, and chronic infections with deterioration of renal function

·         Types of Urinary Diversion

·         Incontinent urinary diversion

§  Ileal conduit AKA ileal loop – pg. 1159, Table 46-24 for Patient Teaching

o   Reroutes urine from kidneys to pouch in abdominal wall created from a segment of the ileum; urine drains continuously from ilea pouch

o   Ureters are implanted into part of ileum or colon that has been resected from intestinal tract, abdominal stoma is created

·         Continent urinary diversion

§  An intraabdominal urinary reservoir that can be catheterized or that has an outlet controlled by the anal sphincter.

§  Self-catheterize every 4-6 hrs, does not need to wear external attachments

Ø  Preoperative Management

o   Teach the patient with a continent diversion (e.g., Indiana pouch) to catheterize at least every 6 hours and irrigate the pouch daily

o   Assess ability & readiness to learn before initiating a teaching program

o   Reduce anxiety

o   Assess pt’s support systems and ability to care for self after surgery

o   Address concerns about changes in body image & loss of sexual or reproductive function

o   Administer antibiotics for 24 hrs before surgery

o   Begin bowel preparations about 4 days prior to surgery

o   Administer enema on night before surgery to clear fecal matter from bowel

Ø  Postoperative Management

o   After pelvic surgery, there is an increased incidence of thrombophlebitis, small bowel obstruction, and UTI

o   NPO status and NG tube are necessary for a few days.

o   Advise the patient that mucus in the urine is a normal occurrence

o   Encourage a high fluid intake to flush the ileal conduit or continent diversion.

o   Prevent injury to the stoma & maintain urine output

o   F/U in 3-4 weeks after surgery

o   Teach pt symptoms of obstruction/ infection, care of the ostomy

o   Ileal conduit is fitted for a permanent appliance 7-10 days after surgery

o   Inspect stoma & incision for bleeding

o   Patient should not expect a normal desire to void

§  To avoid bladder overdistention, patients should void at least every 2 to 4 hours, sit during voiding, and practice pelvic floor muscle relaxation to aid voiding

Glomerulonephritis pg 1132  Table 46-9

Ø  Patho

·         Inflammation of the glomeruli, which affects both kidneys equally and is the 3^rd leading cause of renal failure in the United States. Glomerulonephritis is the result of the immunologic process involving the urinary tract.

Ø  Assessment of Acute and Chronic

·         acute glomerulonephritis – most common in children and young adults

o   Develops 5-21 days after an infection of the tonsils, pharynx, or skin (a streptococcal sore throat, impetigo) by nephrotoxic strains of group A B-hemolytic streptococci

·         Chronic Glomerulonephritis– reflects the end stage of glomerular inflammatory disease result from glomerulonephritis & nephrotic syndrome

o   Tx for chronic: treat htn, UTI, protein & phosphate restrictions; may slow progression of kidney disease

Ø  Clinical manifestations

·         acute glomerulonephritis

o   Edema

o   HTN

o   oliguria,

o   Hematuria with a smoky/rusty appearance

o   Proteinuria

o   Periorbital edema

o   Ascites

o   Abdominal or flank pain

o   Elevated BUN and creatinine

·         Chronic Glomerulonephritis

o   proteinuria

o   hematuria

o   slow development of uremia

o   abnormality on a urinalysis

o   elevated blood pressure

**Symptoms develop slowly over time; patients are often unaware that progressive kidney impairment is occurring. Chronic glomerulonephritis progresses insidiously toward renal failure in 2 to 30 years. **

Ø  What labs would you expect to be abnormal?

·         CBC with WBC differential,

·         Elevated BUN& creatinine levels,

·         Urinalysis- hematuria, proteinuria, hypoalbuminemia,

·         positive ASO

·         positive streptococcal exoenzymes

·         elevated ESR

·         decreased creatinine clearance

·         decreased Na

·         elevated K

·         Positive renal biopsy

Ø  Risk factors to assess

·         Exposure to drugs, immunizations, microbial infections, viral infections (Hepatitis B or C, measles, HIV)

·         Immune disorders(systemic lupus erythematosus& systemic sclerosis)

·         Recent respiratory or skin infections (Strep throat, impetigo)

·         Heart infections (endocarditis)

·         Goodpasture syndrome

Ø  Indications that treatment is effective

·         Client is able to resume usual activities of ADLs

·         Demonstrates knowledge of diet & fluid restrictions

·         Maintains desired weight

·         Signs of fluid overload & N/V are absent

Ø  Implementation

·         Treatment is supportive and symptomatic (management).

·         Rest until signs of glomerular inflammation (proteinuria, hematuria) & htn subside

·         Edema – restrict Na & fluid intake & administer diuretics

·         HTN – anti-hypertensive drugs

·         Dietary protein intake may be restricted if there is a ↑ in nitrogenous waste, ↑BUN value

·         Low-protein, low-sodium, fluid-restricted, high carbohydrate diets

·         Antibiotics – given only if streptococcal infections is still present

·         Encourage early diagnosis & tx of sore throats, & skin lesions

·         Encourage to take the full course of antibiotics

·         Good personal hygiene

·         Monitor VS, I & O, daily weight, urinary output

Nephrotic Syndrome             Page 1134

Ø  Patho

·         Results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and tissue edema.

Ø  Etiology

·         Allows plasma proteins to escape into urine, result in hypoalbuminemia w/ decreased oncotic pressure in plasma & fluid shifts from intravascular to interstitial spaces = edema

·         Na & H2O retention = edema

·         Thromboemboli (mobilized blood clots) are common complication, may occlude peripheral veins & arteries, renal veins

Ø  Assessment

·         Peripheral edema

·         Massive proteinuria

·         HTN

·         Hyperlipidemia

·         Hypoalbuminemia

·         Ascites

·         Anasarca (massive generalized edema)

·         Fat bodies (fatty casts) in urine

·         Labs: decreased albumin, decreased protein, elevated cholesterol, hypocalcemia, hyperparathyroidism, osteomalacia, loss of clotting factors 

Ø  Nursing diagnosis

·         Fluid overload

·         Fatigue

·         Insufficient ability to perform usual role

Ø  Implementation

·         Control edema:

o   Na restricted diet

o   Avoid Na containing drugs (OTC)

o   Diuretics that block aldosterone formation (Lasix &Edecrin)

o   Administer salt-poor albumin to reduce fluid retention

·         Provide high protein diet, high-calorie diet

·         Maintain bed rest until edema begins to subside

·         Administer drug therapy

o   ACE to reduce protein loss

o   NSAIDs to reduce proteinuria

o   Colestipol (Colestid) & lovastatin (Mevacor) to help reduce cholesterol level

o   Corticosteroids & cyclophosphamide in tx severe cases of nephrotic syndrome

·         Monitor I & Os, daily weights, measure abdominal girth and extremity size

·         Clean the edematous skin carefully

·         Avoid trauma

·         Serve small, frequent meals

·         Take measures to avoid exposure to person w/known infections  

·         Provide support (coping with altered body image, due to embarrassment of edematous appearance)

Polycystic Kidney Disease(PKD)    pg. 1143

Ø  PKD – Hereditary disease characterized by cyst formation in cortex/medulla& massive kidney enlargement, affecting both children and adult.

o   Most common life-threatening genetic disease in the world.

Ø  Patho/etiology

·         Cysts filled with pus or blood enlarge and multiply, kidneys enlarge, renal blood vessels nephrons are compressed & obstructed, & functional tissue is destroyed.

·         Often develop cysts elsewhere in body such as liver, spleen, pancreas, brain, aneurysms in aorta and/or brain

Ø  S/S Polycystic Kidney Disease (PKD)     

·         HTN

·         Hematuria

·         Feeling of heaviness in the back, side, or abdomen

·         UTI

·         Urinary Calculi

·         Palpably enlarged kidneys bilaterally

** Early in the disease patients are generally asymptomatic. Symptoms appear when the cysts begin to enlarge**

Ø  Risk factorsPolycystic Kidney Disease (PKD)     

·         Hereditary disease:

o   Autosomal dominant disorder affects adults

o   Autosomal recessive disorder affects children; rapidly progressive

Ø  Implementation

·         Provide support care – help client cope w/ symptoms, no effective tx is available

·         Fluid restriction

·         Antihypertensive drug

·         Nephrectomy

·         Dialysis

·         Kidney transplant

·         Antibiotics if infection develops

Ø  Patient teaching

·         Maintain general health status

·         Prevent UTI& recognize early signs of infection

·         Avoid nephrotoxic medications & check w/ provider before taking any new drug

·         Genetic counseling & screening of family members for evidence of disease

·         Referral to support groups (American Kidney Foundation)

Procedures/Labs     pg 1114

Ø  BUN(Blood Urea Nitrogen)

o   Used to identify the presence of renal problems.

o   The concentration of urea in blood is regulated by the rate at which kidney excretes urea.

o   Normal range: 6-20 mg/dL

Ø  Creatinine

o   More reliable than BUN as a determinant of renal function.

o   Creatinine is the end product of muscle and protein metabolism and is liberated at a constant rate.

o   Normal range: 0.6- 1.3 mg/dL

Ø  GFR  (Glomerular filtration rate)

o   The amount of blood filtered by the glomeruli in a given time (minutes)

o   Normal: 125 mL/min