NURS223 Med Surg Nursing 2: Exam 5
A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of uncontrolled hypertension and coronary artery disease. You're assessing the new medication orders received for this patient. Which medication ordered by the physician will help treat the patient's hypertension along with providing a protective mechanism to the kidneys? 1. Lisinopril 2. Metoprolol 3. Amlodipine 4. Verapamil
1
A client with renal failure is receiving epoetin alfa (Epogen) to support erythropoiesis. The nurse questions the client about compliance with taking which of the following medications that supports red blood cell (RBC) production? 1) iron supplement 2) zinc supplement 3) calcium supplement 4) magnesium supplement
1
A patient with stage 4 chronic kidney disease asks what type of diet they should follow. You explain the patient should follow a:* 1. Low protein, low sodium, low potassium, low phosphate diet 2. High protein, low sodium, low potassium, high phosphate diet 3. Low protein, high sodium, high potassium, high phosphate diet 4. Low protein, low sodium, low potassium, high phosphate diet
1
The client hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism. The priority action for the nurse is to: 1) discontinue dialysis and notify the physician 2) monitor vital signs every 15 minutes for the next hour 3) continue dialysis at a slower rate after checking the lines for air 4) bolus the client with 500 ml of normal saline to break up the air embolus
1
The client with chronic renal failure has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. The nurse should immediately: 1) change the dressing 2) reinforce the dressing 3) flush the peritoneal dialysis catheter 4) scrub the catheter with povidine-iodine
1
The patient has been NPO but is now tolerating food. What education will the nurse provide regarding nutrition? 1. Small and frequent meals are best. 2. Use of alcohol and caffeine should be consumed in moderation. 3. Expect to experience nausea and vomiting as you begin to consume foods. 4. Low-carbohydrate, high-protein, and high-fat foods should be consumed.
1
A patient with end-stage kidney disease (ESKD) has this serum laboratory analysis: K+ 5.9 mEq/L Na+ 152 mEq/L Creatinine 6.2 mg/dL BUN 60 mg/dL What is the priority nursing intervention? 1. Assess heart rate and rhythm. 2. Implement seizure precautions. 3. Assess the patient's respiratory status. 4. Evaluate the patient's acid-base balance.
1 Rationale: Patients with ESKD experience significant fluid and electrolyte imbalances that are managed with medications and dialysis. Hyperkalemia can be a life-threatening event. In patients with kidney disease, the myocardial response (heart rate and rhythm) to hyperkalemia should be assessed to effectively determine appropriate treatment. High sodium can increase the patient's risk for seizures, excessive fluid balance will negatively effect breathing, and patients with ESKD experience acid-base imbalances from an inability to synthesize bicarbonate.
A 55-year-old patient with a history of alcohol abuse spanning 10 years has been diagnosed with cirrhosis. The patient will be undergoing abdominal paracentesis on the medical unit today. Which assessment finding would alert the nurse that the paracentesis has been successful? 1. Decrease in post-procedure weight 2. No residual obtained during procedure 3. Substantial decrease in blood pressure 4. Immediate sensation of a need to urinate
1 - take a liter or more out
The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? 1. Immediately start enteral feeding to prevent malnutrition. 2. Insert an NG and maintain NPO status to allow pancreas to rest. 3. Initiate early prophylactic antibiotic therapy to prevent infection. 4. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
2
A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has "eaten and drunk quite a bit." He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis. Which laboratory finding corroborates the diagnosis of acute pancreatitis? 1. Serum lipase, 150 U/L 2. Serum amylase, 250 U/L 3. Serum glucose, 80 mg/dL 4. White blood cells (WBCs), 6000 mcL
2 Amylase - Normal is 30-220 Lipase - Normal 0-160
A patient is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) 1. Preparing to insert an esophageal tamponade tube 2. Assessing the client's neurologic status every 2 hours 3. Evaluating the client's serum ammonia level 4. Making sure the client's fingernails are short 5. Monitoring the client's hemoglobin and hematocrit levels
2, 3
The nurse is taking care of a patient with cardiogenic shock who has a intra-aortic balloon pump in for treatment. What should the nurse include in the care plan to assess that an acute kidney injury is prevented? 1. Blood pressure 2. Pedal pulse and capillary refill <3 seconds 3. Urine output >30ml/hr 4. A/O x3
3
Which patient below is at MOST risk for CHRONIC pancreatitis?* 1. A 25 year old female with a family history of gallstones. 2. A 35 year old male who reports social drinking of alcohol. 3. A 15 year old female with cystic fibrosis. 4. A 66 year old female with stomach cancer.
3
Phases of Peritoneal Dialysis
3 Phases of peritoneal dialysis: Infusion: 2-3 Liters - takes 5-20 minutes. The docs can add different things to dialysate (ex: insulin, antibiotics, or dextrose- 4.25à the higher the dextrose concentration, the more water will be removed. Dwell- solution sits in the abd. Cavity for 20-30 mins Drain- should look colorless, pale, straw with a little blood. Don't want to see cloudy fluid- Indicates infection **exam**
A client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client? 1. Decreasing the client's dietary protein intake 2. Applying pressure when giving I.M. injections 3. Administering vitamin K subcutaneously 4. Keeping the client's fingernails short and smooth
4
Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects? 1. Tachycardia 2. Constipation 3. Jaundice 4. Hyperkalemia
4
The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: 1) during dialysis 2) just before dialysis 3) the day after dialysis 4) on return form dialysis
4
When might you see asterixis?
Acute Liver Failure
Which lab value is the nurse most concerned with for a patient with pancreatitis?
Amylase
Acute Pancreatitis
Amylase and lipase secrete when we eat - premature activation of enzymes - stays in pancreas instead of stomach - enzymes start to destruct pancreas cells Causes - trauma, tumors, alcohol, drugs, smoking, gull stones, hyperlipidemia Sudden and severe abdominal pain, worse when lying down, nausea, vomiting, weight loss, greys turner sign- acumoses on flanks, jaundice, absent or decreased bowel sounds, moist skin, fruity breath, acites, hyperactive reflexes,
Hypotension w/ dialysis
Antihypertensive therapy and rapid fluid depletion during dialysis can cause hypotension. NURSING ACTIONS ●● Carefully replace fluid volume by infusing IV fluids or colloid. Slow the dialysis exchange rate. ●● Lower the head of the client's bed. ●● For severe hypotension that does not respond to fluid replacement, discontinue the dialysis.
Priority assessment prior to giving Kayexalate is?
Bowel sounds
Stages of CKD
CKD is comprised of five stages. ●● Stage 1: Minimal kidney damage when GFR within expected reference range (greater than 90 mL/min) ●● Stage 2: Mild kidney damage with mildly decreased GFR (60 to 89 mL/min) ●● Stage 3: Moderate kidney damage with moderate decrease in GFR (30 to 59 mL/min) ●● Stage 4: Severe kidney damage with severe decrease in GFR (15 to 29 mL/min) ●● Stage 5: Kidney failure and end‑stage kidney disease with little or no glomerular filtration (less than 15 mL/min)
Which drug does the nurse anticipate administering to the patient with acute glomerulonephritis with a high K+ level?
Calcium gluconate
Hepatic Encephalopathy
Changes in LOC can happen quickly Coarse tremor of wrists and fingers Assess ammonia - increased with cirrhosis - norm is 6-47 - will increase Base treatments off neuro status Lactulose - binds to ammonia and comes out in stool Reduce dietary protein - can increase ammonia levels Neomycin/rifaximin - broad spectrum antibiotic Metro/vanco - Watch labs - potassium - changes in LOC assess every 2 hours Use bed/chair alarms, toileting schedules, sitter if necessary Stool - watch for cdiff
You work in a dialysis clinic, what can you delegate to a dialysis technician?
Check the pt's VS
During the draining phase of dialysis, you expect to see what kind of fluid?
Clear or straw colored with minimal blood
Vascular Access
Clotting/infection of the access site ●● Anticoagulants prevent blood clots from forming. Monitor for hemorrhage at the insertion site. ●● Cannulation can introduce infections at the access site. ◯◯ Immunosuppressive disorders increase the risk for infection. ◯◯ Advanced age is a risk factor for dialysis‑induced hypotension and access site complications due to chronic illnesses or fragile veins.
Ascites
Collection of fluid in peritoneal cavity Salt and water retention Might look FVO - truly are most likely hypovolemic Pressure on renal arteries - kidneys need more blood flow - hold onto salt and water Monitor resp status, sit patient upright, measure ab girth daily, strict I&O, daily weight, fluid restriction Fever, loss of appetite, pain, LOC changes Start broad spectrum antibiotics Paracentesis - determine bacteria - drain fluid Make sure patient voids Nutrition -adjust diet - low sodium, fluid restriction, watch potassium - spironolactone to draw fluid out
Oliguric Phase
Decrease in urine output approx. 100-400 ml/24 hours. It doesn't respond to fluid challenges and diuretics. increase in creatinine, BUN, Potassium, and Magnesium. Decrease in bicarb and calcium, and GFR. F&E abnormalities, and metabolic acidosis. Can last from 1-2 weeks. Uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop. Diuretic- urine output begins to increase overtime. Tubule damage begins to resolve if injury was not too severe. Labs start to normalize. Characterizing feature in this phase is diuresis (1-3Liters of output/day) HTN, hypovolemia and hypokalemia are present
Esophageal Varices
Dilation of vessels from portal hypertension - fragile, thin walls. Distended Bleeding varices is life threatening - hypovolemic shock Bloody sputum, dark tarry stools, coffee ground emesis Make sure to control bleeding - saline lavage, oxygen, fluids, watch h&h Duodenoscopy can have bands - clamp vessel to slow bleeding - tube in espophagus to put pressure on vessels and slow bleeding - secure airway Vasopressin & octreotide Pantoprazole and protonics to decrease acid and irritation to vessels RBC & plasma - replace blood loss and help bleeding/clotting time
Disequilibrium Syndrome
Disequilibrium syndrome results from too rapid a decrease of BUN and circulating fluid volume. It can result in cerebral edema and increased intracranial pressure. ●● Early recognition of disequilibrium syndrome is essential. Manifestations include nausea, vomiting, changes in level of consciousness, seizures, and agitation. ●● Advanced age is a risk factor for dialysis disequilibrium and hypotension due to rapid changes in fluid and electrolyte status. NURSING ACTIONS ●● Use a slow dialysis exchange rate, especially for older adult clients and first‑time hemodialysis. ●● Administer anticonvulsants or barbiturates if the client requires them.
Chronic Pancreatitis
Due to progressive destruction of pancreas Alcohol is primary risk factor Chronic obstructive pancreatitis due to stones Pain management, pancreatic enzyme replacement - pancrealipase every time they eat - full glass of water and wipe mouth/rinse to get enzymes out. Increase calorie intake and avoid foods high in fat. Avoid alcohol. Treat patient like type 1 diabetic
Esophageal Varices Treatment
EGD with banding Blakemore tube placement Long term propranolol Vasopressin, octreotide Pantoprazole PRBC, FFP, Cryro Transjugular Intrahepatic Portal-Systemic Shunt -TIPS - large sheath in jugular vein, use balloon to enlarge vein - risk of bleeding is significant
Chronic or Maintenance Dialysis
ESRD - fluid overload not responsive to diauretics and fluid restrictions Presence of uremic S/S affecting all body systems (N/V) Hyperkalemia - pericardial friction rub
SATA: Pt teaching for peritoneal dialysis must include:
Eating more protein Keep catheter site clean and dry Maintain clean technique for exchanges Notify HCP about purulent drainage
Calcium carbonate impacts the creatinine level of a patient with kidney disease
False
During the infusion phase of dialysis approximately 4-5 liters of fluid will be infused
False
It is ok for a patient with liver cirrhosis to drink alcohol
False
Occult blood means blood in urine
False
Patients with CKD should consume a lot of dairy products
False
Risk of contracting Hep E is minimal when traveling to different countries and drinking an unknown water supply
False
The CRT lab value is most important to report prior to a patient with ESKD receiving epoetin alfa
False
The patient has a K+ of 3.1. There are orders for sprionolactalone and furosemide. Give the furosemide first.
False
Diagnostic Findings of CRF
GFR- The lower the GFR, the more kidney damage is done. Electrolytes-Na and K-early chronic renal failure-hyponatremic. In the later stages, pt's are hypernatremic and K will go up. Acid-base balance-as nephrons die-acid builds up and the pt. gets metabolic acidosis. Hematological-the pt. is anemic because of a decrease in erythropoietin and RBC Calcium and phosphorous-these lab values go hand in hand. The lower the Ca values, the more at risk the pt. is for sucking Ca out of the bone and increasing the serum Ca Effects on phosphate: phosphate retention àhyperphosphatemia. Binding of phosphate with calcium. This decreases the serum calcium. The pt. is not making good ca because of low Vitamin D. (High phosphate levels=low Ca levels.) The parathyroid gland releases PTH-the parathyroid gland controls the amount of phosphate excreted. In CRF, the parathyroid gland is not doing its job. So, the more the body secretes PTH, the more Ca is released from the bones. So this gives you an increased serum Ca level which will cause binding of phosphate with calcium and cause metastatic calcification. With increased serum ca levels-crystals can lodge in your heart, brain etc., so it puts you at risk for metastatic calcification(crystal like clots-detrimental to pt's.) Effects on calcium There is a decreased production of vitamin Dà leads to a decreased absorption of calcium from the GI tractà decreased serum calcium levelà causes a release of PTH from the parathyroid gland-which controls the amount of phosphorous excretedà which causes a release of calcium stored in the bonesà leads to an increased serum calcium levelà So there is binding of phosphorous with calcium
Most important finding to report to the provider about a patient who just received an AVG in their forearm?
Hand is cold below AVG insertion site
What should you have the patient do prior to having a paracentesis?
Have them urinate
SATA: Which hepatitis' are fecal-oral
Hep A & E
Hepatitis
Hepatitis A- spread fecal-oral route; usually not life threatening Hepatitis B- Bloodborne Hepatitis C- Bloodborve; don't clear virus and can infect others for life Hepatitis D- Coinfection with Hep B Hepatitis E- water-borne infection caused by fecal contamination; self-limiting and resolve on own
Nursing Care for Peritoneal Dialysis
INTRAPROCEDURE NURSING ACTIONS ●● Monitor vital signs frequently during initial dialysis of clients in a hospital setting. ●● Monitor serum glucose level (dialysate contains glucose, a hypertonic solution). ●● Record the amount of inflow compared to outflow of dialysate. ●● Monitor the color (should be clear, light yellow) and amount (should equal or exceed the amount of dialysate inflow) of outflow. ●● Monitor for signs of infection (fever; bloody, cloudy, or frothy dialysate return; drainage at access site) and for complications (respiratory distress, abdominal pain, insufficient outflow, discolored outflow). ●● Check the access site dressing for wetness (risk of dialysate leakage) and exit‑site infections. ●● Warm the dialysate prior to instilling. Avoid the use of microwave ovens, which cause uneven heating. ●● Adhere to the times for infusion, dwell, and outflow. ●● Maintain surgical asepsis of the catheter insertion site and when accessing the catheter. ●● Keep the outflow bag lower than the client's abdomen (drain by gravity, prevent reflux). ●● Reposition the client if inflow or outflow is inadequate. ●● Carefully milk the peritoneal dialysis catheter if a fibrin clot has formed. ●● Provide emotional support to the client and family.
Which OTC medication would you be concerned about when assessing your patient who has jaundice?
Ibuprofen
Acute Kidney Injury (AKI)
In most cases, the findings of AKI are related to waste buildup and decreased urine output. However, almost every body system can be affected. ●● CARDIOVASCULAR: fluid overload (dependent and generalized edema), dysrhythmia (hyperkalemia) ●● RESPIRATORY: crackles, decreased oxygenation, shortness of breath ●● RENAL: scant to normal or excessive urine output, depending on the phase; possible hematuria ●● NEUROLOGICAL: lethargy, muscle twitching, seizures ●● INTEGUMENTARY: dry skin and mucous membranes
What would you expect to do first when caring for the BPH patient with elevated CRT and BUN?
Insert a catheter
Pancreatic Carcinoma
Leading cause of death - found in late stages Chemo and radiation; biliary stents to reduce obstructions Whipple procedure - Long recovery NPO until GI tract has stabilized Semi fowlers position - provide with walker so they can remain hunched over Watch sodium potassium and calcium - make sure patient is hydrated Hourly blood sugars - hyper/hypo glycemia - insulin drip
Hepatic Cirrhosis
Liver cells can regenerate with healthy cells. Scarring is irreversible - unable to regenerate Postnecrotic - caused by hep B C D , Tylenol - max dose is 4,000 mg for 24 hours Laenne's - alcohol Billiary tree obstruction or autoimmune disease - gall stones, tumor, masses s/s - fatigue, anorexia, ab pain, vomiting Late s/s - jaundice, itchy skin (peritus), risk for bleeding, yellowing sclera, bruising, pulm erythema, blood vessels on nose cheecks upper thorax shoulders, acites, peripheral edema, vitamin deficiency, fruity breath, tremor in wrist and fingers, elevated ammonia, distended abdominal veins, hernia, resp distress Nutrition - high carb and protein, low fat, vitamins - low sodium with fluid overload, low protein with encephalopathy due to elevated ammonia, fluid restrictions Portal hypertension
Liver Transplant
Liver doner- take portion of liver because healthy liver cells will regenerate Candidates - severe cardiac/resp disease Alcohol/substance free for 6 months before eligible Watch for infection, fever, jaundice, foul smelling drainage, RUQ pain, tachycardia, LFTs Take immunosuppressants and antibiotics
Non-Oliguric phase
May take the place of oliguric phase. Urine output remains near normal. The pt. still puts out urine but their kidneys are just not working. Decreased renal function with increasing nitrogen retention, yet actually excrete normal amounts of urine. This occurs predominantly after exposure of the pt. to nephrotoxic agents.
AKI Treatments
NURSING CARE ●● Identify and assist with correcting the underlying cause. ●● Monitor central venous pressure (CVP) and for hypotension and tachycardia. ●● Monitor fluid intake and output strictly. ●● Review laboratory values (BUN, creatinine, electrolytes, hematocrit). ●● Avoid using nephrotoxic medications. If necessary, give these medications sparingly and decrease the medication dosage. ●● Assess for edema and manifestations of heart failure or pulmonary edema. ●● Restrict fluid intake as prescribed. ●● Assess for flank pain, nausea, and vomiting (nephrolithiasis). ●● Monitor for ECG dysrhythmias and changes (tall T waves). ●● Monitor daily weights. ●● Assess for changes in urination stream or difficulty starting the stream of urine. ●● Assess the urine for blood or particles. ●● Treat fever or infection promptly to prevent increase in the client's metabolic rate. ●● Provide skin care to prevent injury (bathe with cool water, reposition frequently, provide adequate moisture). ●● Provide psychosocial support to the client and family. Teach the client and family about prescribed treatments. ●● Teach the client to perform coughing and deep breathing exercises, if lethargic. NUTRITION ●● Implement potassium, phosphate, sodium, and magnesium restrictions, if prescribed (depending on the stage of injury). ●● Restrict fluid intake, if prescribed. ●● High‑protein diet to replace the high rate of protein breakdown due to stress from the illness. Possible total parenteral nutrition (TPN). MEDICATIONS ●● Administer IV fluid therapy as a fluid challenge to promote kidney perfusion, or as fluid replacement if the client is in the diuretic phase. ●● Administer diuretics (furosemide, mannitol, ethacrynic acid) to promote increased filtration of blood by kidney. ●● For AKI caused by medication nephrotoxicity, administer calcium channel blocker to prevent the movement of calcium into the kidney cells and to maintain cell integrity and increase the glomerular filtration rate (GFR). ●● Sodium polystyrene sulfonate replaces sodium with potassium in the intestinal tract to promote potassium excretion. ●● Sorbitol induces a bowel movement to promote excretion of excess potassium. ●● In an emergency, IV medications (dextrose, insulin and calcium) can be required to reduce potassium. ●● Administer sodium bicarbonate if the client has severe metabolic acidosis. ●● For hyperphosphatemia, administer phosphate‑binding agents. THERAPEUTIC PROCEDURES Continuous renal replacement therapy, hemodialysis, peritoneal dialysis
Expected Findings of ESRD
Nausea, fatigue, lethargy, involuntary movement of legs, depression, intractable hiccups In most cases, findings of chronic kidney disease are related to fluid volume overload and include the following. NEUROLOGIC: lethargy, decreased attention span, slurred speech, tremors or jerky movements, ataxia, seizures, coma CARDIOVASCULAR: fluid overload (jugular distention; sacrum, ocular, or peripheral edema), hypertension, dysrhythmias, heart failure, orthostatic hypotension, peaked T wave on ECG (hyperkalemia) RESPIRATORY: uremic halitosis with deep sighing, yawning, shortness of breath, tachypnea, hyperpnea, Kussmaul respirations, crackles, pleural friction rub, frothy pink sputum HEMATOLOGIC: anemia (pallor, weakness, dizziness), ecchymoses, petechiae, melena GASTROINTESTINAL: ulcers in mouth and throat, foul breath, blood in stools, vomiting MUSCULOSKELETAL: osteodystrophy (thin fragile bones) RENAL: urine contains protein, blood, particles; change in the amount, color, concentration SKIN: decreased skin turgor, yellow cast to skin, dry, pruritus, urea crystal on skin (uremic frost) REPRODUCTIVE: erectile dysfunction
Nursing Care for Hemodialysis: Safety measures when a pt. undergoes dialysis
No BP, no blood draws, no IV fluids through fistula POSTPROCEDURE NURSING ACTIONS ●● Monitor vital signs and laboratory values (BUN, serum creatinine, electrolytes, Hct). Decreases in blood pressure and changes in laboratory values are common following dialysis. ●● Compare the client's preprocedure weight with the postprocedure weight as a way to estimate the amount of fluid the procedure removed. 1 L fluid equals 1 kg (2.2 lb). ●● Assess for the following. ◯◯ Complications (hypotension, clotting of vascular access, headache, muscle cramps, bleeding) ◯◯ Indications of bleeding or infection at the access site ◯◯ Signs of disequilibrium syndrome ◯◯ Signs of hypovolemia (hypotension, dizziness, tachycardia) ●● Avoid invasive procedures for 4 to 6 hr after dialysis due to the risk of bleeding as a result of anticoagulation.
Diuretic Phase
Occurs when the source of the obstruction has been removed but there is residual scarring and edema of the renal tubules remains. A gradual increase in u.o. which signal that GFR has started to recover. The pt. will have a lot of urine in this phase-about 4 L in 24 hours. pt. just can't concentrate their urine (Increased Specific gravity). Gradual onset-(2-6 weeks) after the oliguric phase. Electrolyte losses because they are putting out so much urine. Monitor them for dehydration-administer crystalloids (D5W or NS) to prevent dehydration. Monitor their BUN and creatinine levels-these will level off at a lower level and plateau up and plateau down. GFR will be increased (this increase contributes to the passive loss of electrolytes which requires the admin of IV crystalloids), u.o. will be 2-4 L per day, and the Recovery- increase in GFR. BUN, Creat, electrolytes and other assessment findings start to normalize
Phases of AKI
Onset (Initiation phase) Oliguric phase Diuretic phase Recovery phase Non-Oliguric phase
Post-Transplant Complications
Organ rejection NURSING ACTIONS: Monitor for and report manifestations of rejection immediately. Hyperacute: Occurs within 48 hr after surgery ●● ETIOLOGY: An antibody‑mediated response causing small blood clots to form in the transplanted kidney that occlude vessels and result in massive cellular destruction. The process is not reversible. ●● FINDINGS: Fever, hypertension, pain at the transplant site ●● TREATMENT: Immediate removal of the donor kidney Acute: Occurs 1 week to 2 years after surgery ●● ETIOLOGY: An antibody mediated response causing vasculitis in the donor kidney, and cellular destruction starts with inflammation that causes lysis of the donor kidney ●● FINDINGS: Oliguria, anuria, low‑grade fever, hypertension, tenderness over the transplanted kidney, lethargy, azotemia, and fluid retention ●● TREATMENT: Involves increased doses of immunosuppressive medications Chronic: Occurs gradually over months to years ●● ETIOLOGY: Blood vessel injury from overgrowth of the smooth muscles of the blood vessels causing fibrotic tissue to replace normal tissue resulting in a nonfunctioning donor kidney ●● FINDINGS: Gradual return of azotemia, fluid retention, electrolyte imbalance, and fatigue ●● TREATMENT: Conservative (monitor kidney status, continue immunosuppressive therapy) until dialysis is required CLIENT EDUCATION ●● Teach the client to monitor for manifestations of rejection and to contact the provider immediately. ●● Instruct the client that rejection is diagnosed through a kidney scan and kidney biopsies. ●● Instruct the client to adhere to the pharmacological regimen. Ischemia A delay in transplanting the donor kidney after harvesting can result in hypoxic injury of the donor kidney. NURSING ACTIONS ●● Monitor urine output, serum creatinine, and BUN levels to detect failure of the transplanted kidney. ●● Report hourly output volumes less than 30 mL/hr. ●● Assist the client with dialysis as indicated. ●● Prepare the client for a kidney biopsy to distinguish ischemia from organ rejection. CLIENT EDUCATION: Advise the client that dialysis might be needed until the donor kidney heals. Renal artery stenosis Renal artery stenosis is due to scarring of surgical anastomosis. NURSING ACTIONS ●● Monitor for and report hypertension, bruit over artery anastomosis site, and decreased kidney function, such as oliguria and elevated BUN and creatinine. ●● Prepare the client for a kidney scan to verify the status of renal blood flow. ●● Angioplasty and/or surgical intervention might be necessary. CLIENT EDUCATION: Advise the client to monitor for peripheral edema and have blood pressure checked often. Thrombosis A blood clot can form in a major vessel of the transplanted kidney. NURSING ACTIONS ●● Monitor for and report a sudden decrease in urine output. ●● Prepare the client for emergency surgery requiring an emergency transplant nephrectomy (removal of the transplant kidney). CLIENT EDUCATION ●● Keep the client informed about the risk of a blood clot. ●● Advise the client to inform the provider of a sudden decrease in urine output. Infection ●● Infection is a common cause of first‑transplant‑year morbidity and mortality. ●● Detection of early manifestations of infection are difficult when the client receives immunosuppressive therapy. Vague symptoms include low‑grade fevers, mild reports of discomfort, and mental status changes. NURSING ACTIONS ●● Give high priority to infection control measures, such as frequent hand hygiene. ●● Monitor for and report manifestations of a localized (wound) or systemic infection (pneumonia, sepsis). CLIENT EDUCATION ●● Instruct the client to monitor for and report manifestations of infection, such as fever, incisional drainage, and redness. Later indications of infection can include fatigue and discomfort. Report any manifestations of infection to the provider. ●● Educate the client and family about the increased risk for infection during immunosuppressant therapy and infection control measures, such as frequent hand hygiene and avoiding crowds and people who have a communicable disease. The client might need to wear a face mask when out in public. ●● Instruct the client to adhere to the pharmacological regimen.
Which patient is able to receive CVVH?
Patient with kidney failure who is in septic shock
Complications of Peritoneal Dialysis
Peritonitis Peritoneal dialysis can allow micro‑organisms into the peritoneum and cause peritonitis. NURSING ACTIONS ●● Maintain surgical asepsis during the procedure. ●● Monitor for infection, such as fever, purulent drainage, redness, swelling, and cloudy or discolored drained dialysate. CLIENT EDUCATION ●● Educate the client to use strict sterile technique during exchanges. ●● Instruct the client to notify the provider about any indications of infection. Infection at the access site ●● Infection at the access site can result from leakage of dialysate. Access‑site infections can cause peritonitis. ●● Advanced age is a risk factor for access site complications due to chronic illnesses and/or fragile veins. NURSING ACTIONS ●● Maintain surgical asepsis at the access site. ●● Assess the site for wetness from a leaking catheter. ●● Monitor for infection, such as fever, purulent drainage, redness, or swelling. CLIENT EDUCATION ●● Educate the client to use strict sterile technique during exchanges. ●● Instruct the client to notify the provider of any indications of infection. ●● Advise the client to assess the site for leaks, and prevent tugging or twisting of the tubing. Protein loss Peritoneal dialysis can remove protein from the blood as well as excess fluid, wastes, and electrolytes. NURSING ACTIONS ●● Increase the client's dietary intake of protein over predialysis restrictions. ●● Monitor serum albumin levels. CLIENT EDUCATION: Instruct the client to follow the renal diet with an increase in dietary protein. Hyperglycemia and hyperlipidemia ●● Hyperglycemia can result from the hyperosmolarity of the dialysate. ●● The blood can absorb glucose from the dialysate. ●● Hyperlipidemia can also occur from long‑term therapy and lead to hypertension. NURSING ACTIONS ●● Monitor serum glucose. ●● Administer insulin for glycemic control. ●● Administer antilipemic medication for triglyceride control. CLIENT EDUCATION ●● Instruct the client to check serum glucose. ●● Instruct the client to follow a the diet the provider recommends. ●● Instruct the client to take antihypertensive medication for elevated blood pressure. Poor dialysate inflow or outflow ●● Obstruction or twisting of the tubing can decrease the flow. ●● Constipation is a common cause of poor inflow or outflow. NURSING ACTIONS ●● Reposition the client if inflow or outflow is inadequate. ●● Milk the tubing to break up fibrin clots. ●● Check the tubing for kinks or closed clamps. ●● Tell the client to avoid constipation by using stool softeners and consuming a diet high in fiber. CLIENT EDUCATION ●● Advise the client to check the tubing for kinks, and teach the client how to remove a fibrin clot. ●● Remind the client to monitor the inflow and outflow, and to change position or lower or raise the dialysate bag to improve flow. ●● Advise the client to prevent constipation with diet and stool softeners. ●● Encourage the client to lie supine with head slightly elevated during CCPD and APD treatment
Hepatorenal Syndrome
Poor prognosis Sudden decrease in urine flow (<500ml/24 hours) Elevated BUN and Creat Increased urine osmolarity
Portal Hypertension
Portal vein goes into liver to do filtering - liver isn't able to filter - starts to back up into portal vein and increases pressure Bleeding in GI tract, vessel walls dilate and get very thin Enlarged spleen
What does a patient with kidney failure have the greatest difficulty in secreting?
Potassium
Types of AKI
Prerenal: Occurs as a result of volume depletion and prolonged reduction of blood flow to the kidneys, which leads to ischemia of the nephrons. Occurs before damage to the kidney. Early intervention restoring fluid volume deficit can reverse AKI and prevent chronic kidney disease (CKD). ●● Intrarenal: Occurs as a result of direct damage to the kidney from lack of oxygen (acute tubular necrosis). ●● Postrenal: Occurs as a result of bilateral obstruction of structures leaving the kidney.
Chronic Renal Failure (ESRD)
Progressive, irreversible kidney injury where kidney fxn DOES NOT recover. body's ability to maintain metabolic F&E balance fails, resulting in uremia or azotemia. Slow progression that it takes years before the pt. will have any S&S.
Hemodialysis
Pt's go to dialysis 3x/week. Works by using passive transfer of toxins by diffusion. Some use anticoagulation (Heparin)- newer machines don't. Used to extract toxic nitrogenous substances from the blood and to remove excess water. Used for pt's not responding to tx. If the K+ is 7 and not responding to tx such as kayexelate and they can't get the K+ down, they will start the pt. on dialysis. If the BUN is too high they will also start dialysis. If pt. has ARF- this dialysis tx will be short-term Cath. will be in subclavian or jugular with an inflow/outflow lumen If pt. only has dialysis 1 or 2 times, will put cath. in femoral artery- not used longterm d/t risk for infection and kinking. Arteriovenous fistula- the preferred method of permanent access that is created surgically. Join an artery to a vein usually an anastomosis between the radial artery and cephalic vein. Most of the time, they will start the pt's off with a fistula. Arteriovenous graft- Can be created subcutaneously interposing a biologic (silicone tube) graft material between an artery and vein. Usually created when the patient's vessels are not suitable for creation of a fistula.
Treatments for Acute Pancreatitis
Rest pancreas - NPO Few days to a week to heal Might need TPN / NG tube Resume diet- bland, low fat, no spices, small frequent meals. Antiemetic as needed, no alcohol intake, no smoking Monitor blood glucose - risk for hyperglycemia Hydration status Watch electrolytes - potassium and calcium can be low With fever- start antibiotics and steroids
What lab should be monitored when certain drugs are given that can be harsh on the kidneys
Serum creatinine
Hepatitis Nursing Interventions
Shellfish - hep A GI upset, vomiting, nausea, diarrhea. Oral hydration or IV, gatorade, pedialyte Hep B - acute infections - supportive care, stays stable - Chronic infections - antiviral meds Hep C- can use medications to maintain virus - patients can have hep c be dormant for some time - Hep D - antivirals Hep E- hydration Continuing inflammation of liver cells with B C and D
SATA: Pt. instructions for pancreatic enzymes(pancrealipase) should include:
Take with each meal Wipe Lips and rinse mouth after taking Drink a full glass of water after taking
Lactulose is effective for the patient with liver cirrohisis and encephalopathy and decreased LOC when:
The patient is A&O x 4
Recovery Phase
This phase can last up to a year. Edema decreases Renal tubules begin to function adequately F&E balance are restored. GFR has returned to 70% to *0% of normal.
What is the purpose of a TIPS procedure?
To decrease incidence of bleeding varices
SATA: risk factors for acute pancreatitis
Trauma Excessive alcohol consumption
Kidney Transplantation
Treatment of choice for pt's with ESRD Live /related donor-pt. will have good urine output after surgery. If kidney from cadaver-may take 2 weeks for kidney to wake up. If kidney does not produce urine output after surgery, pt may need to go on dialysis until the kidney wakes up. Make sure pt is free from infection before transplant. Meds are prescribed after surgery to immunosuppress the pt's immune system so that transplant rejection will not occur. Pt's are tx for dental cavities and gingival infections as well (make sure you look in pt's mouth). POSTPROCEDURE NURSING ACTIONS ●● Assess vital signs every 15 min initially and advance to every hour (follow institutional protocol). Maintain blood pressure within prescribed parameters. ●● Assess intake and output at least hourly. ◯◯ Urine output should be greater than 30 mL/hr. Notify the provider of oliguria evidenced by urine output less than 30 mL/hr. ◯◯ Monitor for abrupt decrease in urine output, indicating rejection, tissue injury, thrombosis of the renal artery, or obstruction in the renal system. ◯◯ Assess urine appearance and odor hourly (initially pink and bloody, gradually returning to clear in a few days to several weeks). ◯◯ Monitor daily urinalysis to check for protein, WBCs, RBCs, ketones, glucose, specific gravity, and pH. ●● Daily weight assists in monitoring fluid status. ●● Monitor for fluid and electrolyte imbalances, such as hypervolemia, hypovolemia, hypokalemia, and hyponatremia. ●● Monitor for manifestations of infection, such as dyspnea, fever, incisional drainage, and redness. ●● Monitor for early manifestations of organ rejection (fever, hypertension, pain at the transplant site). ●● Assess surgical dressing for bloody drainage, which can indicate hemorrhage or hematoma formation. ●● Administer intravenous fluids as prescribed, usually calculated to replace hourly urine output. ●● Administer oral fluids and discontinue IV fluid once bowel function returns and fluids are tolerated. ●● Encourage the client to turn, cough, and deep breathe to prevent atelectasis and pneumonia. ●● Provide urinary catheter care. ◯◯ Attach the large indwelling urinary catheter to dependent bedside drainage. ◯◯ Maintain continuous bladder irrigation as prescribed to prevent obstruction from blood clot formation, which can cause damage to the transplanted kidney. ◯◯ Remove the urinary catheter as soon as possible to decrease the risk of infection. ●● Intervene for oliguria as prescribed. Diuretics and/or dialysis can be necessary until kidney function is satisfactory. ◯◯ Mannitol, an osmotic diuretic, preserves urine flow and reduces the risk of acute kidney injury. Filtered mannitol draws water into the nephrons of the kidney and promotes diuresis. ◯◯ Thiazides and loop diuretics are less effective when filtration rate is lower causing less diuresis. ●● Monitor for excessive diuresis, which can result in hypovolemia and hypotension, and cause reduced blood flow to the graft. Notify the provider immediately. ●● Administer immunosuppressive medications to prevent rejection (prednisone, cyclosporines, or other prescribed medication, and monoclonal antibodies [basiliximab or daclizumab]). ●● Monitor for complications, such as infection, hypovolemia, and fluid retention. ●● Immediately notify the surgeon if any manifestations of organ rejection appear. Administer stool softeners to prevent straining and constipation (risk associated with bowel manipulation during abdominal surgery and the effects of general anesthetics and analgesics). ●● Arrange for counseling for the client and family if necessary. ●● Arrange for post‑transplant follow‑up appointments and interventions
Continuous venovenous hemofiltration (CVVH)
Treatment of choice in pt's with ARF don't have arterial access- only removes fluid - very slowly is tolerated better by the patient It is done in the ICU setting. It is used to manage acute renal failure. This provides continuous slow fluid removal. Therefore hemodynamic effects are mild and better tolerated by pt's with unstable conditions. Continuous Venovenous Hemodialysis ***EXAM*** You will see this used in ******UNSTABLE PATIENTS**** It removes fluid and uremic waste. Blood is pumped from a double-lumen venous catheter through a hemofilter and returned to the patient through the same catheter. In addition to the benefits of filtration, CVVHD uses a concentration gradient to facilitate the removal of uremic toxins and fluid. No arterial access is required. Short term catheters are placed at the bedside and are used for 1-week because of infection. Veins used are subclavian, internal jugular or femoral vein. Perm caths can last longer. There is a notch/cuff which is used for infection. This helps micro-organisms from entering the wound. Want the notch to be inside the pt.
An NG tube may be used rest the GI system and decrease abdominal pain.
True
BPH can cause urinary retention and elevate creatinine and BUN values
True
Hepatitis B, C, and D are often caused by IV drug use
True
If your patient has hyperkalemia, they should be on a cardiac monitor
True
It is important to monitor albumin for a patient who has liver cirrhosis and ascites
True
Pantoprazole is a proton pump inhibitor
True
Patients with CKD need to measure their fluid intake
True
Trousseau's sign is due to hypocalcemia
True
Types of Peritoneal Dialysis
Two types of peritoneal dialysis: Continuous ambulatory PD: 5 different exchanges per day. Can be done at home-it allows more flexibility and remains in the ab for 4 to 5 hours. Less extreme fluctuations in the pt's lab values occur because dialysis is constantly in progress. Because of protein loss with CAPD, the pt. needs to eat high protein, and increase daily fiber to help prevent constipation, which can impede the flow of dialysate into or out of the peritoneal cavity. May be asked to limit their carb intake to avoid excessive wt. gain. Potassium, sodium, and fluid restrictions are not normally needed Continuous cycle PD: This combines overnight intermittent peritoneal dialysis with a prolonged dwell time during the day Need a very stable pt. to do this. The peritoneal cath is connected to a cycler machine every evening and the pt receives 3 to 5 exchanges during the night. In the morning the pt. caps off the cath after infusing 2 to 3 L of fresh dialysate. This dialysate remains in the ab cavity until the tubing is reattached to the cycler machine at bedtime
Complications of Acute Pancreatitis
Watch vitals, electrolytes, hypotension, tachycardia Infection - watch fever, upper gastric pain, n/v, jaundice Type 1 diabetes - lack of insulin, watch blood glucose - for some temporary and some long term Pleural effusion - precursor as pneumonia Monitor coagulation MOF- resp distress, jaundice, oliguria, Hypovolemia
Furosemide
a loop‑diuretic administered to excrete excess fluids ●● Avoid administering to a client who has end‑stage kidney disease. ●● Clients can also receive thiazide diuretics, potassium‑sparing diuretics, and osmotic diuretic
Ferrous sulfate
an iron supplement to prevent severe iron deficiency
Intra-renal AKI
damage to kidney tissue; injury to the glomeruli, nephrons, and tubules ( bldding in kidney, emobli in kidney blood vessels, hemolytic uremic syndrome, sepsis, pyelonephritis (infection of kidney), lupus, nephrotoxic drugs (contrast, antibiotics, chemo), cancer, toxins, vasculitis, ischemia (due to respiratory/cardiac arrest)
Onset/Initiation phase
decrease in urine output and increase in creat; Begins with the initial insult and ends when oliguria develops. increase in BUN and Creatinine that can last hours to days. Urine output is 30 ml or less per hour- 50% of the pts. Are noted to be oliguric Oliguric- initiates w/in 1-7 days and lasts 1-2 weeks. Involves hyponatremia, hyperkalemia, hypercalcemia, high BUN and creat. Metabolic acidosis occurs. Patient has fatigue and malaise
Sodium Polystyrene
increases elimination of serum potassium. ●● Restrict sodium intake. Sodium polystyrene contains sodium and can cause fluid retention and hypertension, a complication of CKD.
Post-Renal AKI
obstruction of urine flow; . Pressure rises in the kidney tubules and eventually, the GFR decreases- bladder cancer, cervical, colon, prostate cancers, enlarged prostate, kidney stones, neurogenic bladder, blood clots in urinary tract)
Pre-renal AKI
reduced perfusion; . Is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR. (blood loss, hypovolemic shock, hypotension from BP medications, heart attack/heart failure causing low cardiac output, infection, liver failure, NSAID use, anaphylaxis, burns, dehydration, renal artery stenosis, bleeding/clotting, atherosclerosis)
Epoetin alfa
stimulates production of red blood cells; given for anemia
Acute Dialysis
used for QUICK fluid changes High potassium - Increasing acidosis Fluid overload - Pericarditis Pulmonary Edema - Severe confusion
Peritoneal Dialysis
used to remove toxic substances and metabolic wastes and to re-establish normal F&E balance. May be used for pt's with renal failure who are unable to undergo hemodialysis or renal x-plant. Will put dialysate into the abdomen- let it sit and well- then the drainage tube is unclamped and fluid drains from the peritoneal cavity. Uses a Tenkoff catheter Usually takes 36 to 48 hours to achieve what Hemodialysis accomplishes in 6-8 hours. High risk for peritonitis- infection comes from insertion site- STERILE technique is used. Dialysate is warmed prior to administration to prevent discomfort and abdominal pain and to dilate the vessels of the peritoneum to decrease urea clearance.
Diet Recommendations with Kidney Transplant
●● Low‑fat to decrease cholesterol ●● High‑fiber to avoid constipation ●● Increased protein to promote healing, and rebuild and maintain muscle mass ●● Adequate intake of potassium, calcium, and phosphorus. ●● Restricted sodium intake to prevent fluid retention and hypertension especially when taking prednisone ●● Avoidance of concentrated sugars or carbohydrates to control glycemic factors when on prednisone ●● Magnesium supplements because cyclosporine can reduce magnesium levels
Nursing Care for CRF
●● Report and monitor irregular findings ◯◯ URINARY ELIMINATION PATTERNS: amount, color, odor, and consistency ◯◯ VITAL SIGNS: blood pressure may be increased or decreased ◯◯ WEIGHT: 1 kg (2.2 lb) daily weight increase is approximately 1 L of fluid retained. ●● Assess and monitor vascular access or peritoneal dialysis insertion site. ●● Obtain a detailed medication and herb history to determine the client's risk for continued kidney injury. ●● Control protein intake based on the client's stage of chronic kidney disease and type of dialysis prescribed. ●● Restrict dietary sodium, potassium, phosphorous, and magnesium. ●● Provide a diet that is high in carbohydrates and moderate in fat. ●● Restrict intake of fluids (based on urinary output). ●● Monitor for weight gain trends. ●● Adhere to meticulous cleaning of areas on skin not intact and access sites to control infections. ●● Balance the client's activity and rest. ●● Prepare the client for hemodialysis, peritoneal dialysis, and hemofiltration if indicated. ●● Provide skin care in order to increase comfort and prevent breakdown. ●● Protect the client from injury. ●● Provide emotional support to the client and family. ●● Encourage the client to ask questions and discuss fears. ●● Administer medications as prescribed.
Calcium carbonate
●● Taken with meals to bind phosphate in food and stop phosphate absorption. ●● Take 2 hr before or after other medications ●● Can cause constipation, so clients can require a stool softener