NCLEX Practice Questions: Renal, Nursing: Lines and Studies, Fluid and Electrolyte Review, LAB Values Aultman College, LEARN THIS ****
Continue to monitor VS per institution's protocol?
(in 5 minutes, 15 minutes, 30 minutes, then hourly per W&T textbook)
What are the functions of electrolytes?
- Regulate water distribution - Muscle contractions - Nerve impulse transmission - Blood clotting - Regulate enzyme reactions - Regulate acid base balance
500 ml equals how many lbs?
1
Hypokalemia
Caused by fluid loss, diet, medications S/S leg cramps, muscle weakness, constipation, arrhythmias Treat c diet, IV K+
What are Diagnostics for DIC?
Diagnostics: p. 659t - low fibrinogen, low platelets, increased INR, I d-dimer (by-product of clot breakdown)
Hypervolemia interventions
Dieretics Limit oral intake I+O, weight
Hypercalcemia
Caused by increase parathyroidism, cancer, and immobility S/S renal calculi, fatigue, change in LOC, constipation, cardiac Treated with meds and IV therapy
Hyperchloremia
Caused by loss of fluids from N/V, diarrhea, meds S/S NONE, from fluid loss Hydrate! From hyponatremia, or elevated bicarbonate
What would we administer hypotonic solution for?
Dilute plasma, cell dehydration from conditions like DKA NOT for stroke or brain injury
Hypernatremia
Caused by not drinking, burns and IV S/S thirst, oliguria, increased temperature, increased pulse, confusion Treatment is diet change
Hypermagnesemia
Caused by renal failure, DKA, OTC meds (antacids) Treatment is calcium glucanate (Symptoms of opposite of prefix)
Hyperphosphatemia
Caused by renal failure, excess vit D S/S tetany, EKG changes, hypocalcemia Treat by treating underlying problem
Hyponatremia
Caused by sodium and water loss S/S cramps, N/V, headache Treat with diet, IV fluids, rest
Who are at risk for electrolyte imbalances?
Children, because they are 70% ECF, going back to fluid imbalance. Adults, due to meds, food, and symptoms of problems. Older adults, due to chronic dieases.
Urinalysis Dipstick
Dipstick: pH: 5-9 Protein: < 20 mg/dL Glucose: Neg Ketones: Neg Hgb: Neg Bilirubin: Neg Urobilinogen: up to 1 mg/dL Nitrite: Neg Leukocyte: Neg Esterase: Neg Specific Gravity: 1.001-1.029
Pulmonary Artery Port (yellow) for Swan Ganz
Distal port whose tip rests in pulmonary artery. used for measureing PA pressures and cardiac pressures only, no meds or fluids. Connected to pressure bag.
Low vs high PT/INR levels mean?
Lower level, thicker blood. higher, thinner
Creatinine CRE
Male 0.61-1.21 mg/dL Female 0.51-1.11 mg/dL
Hemoglobin (Hgb)
Male: 12.69-17.4 g/dL Female: 11.7 - 16.1 g/dL
Hematocrit (Hct)
Male: 38-51% Female: 33-45%
RBC
Male: 5.21-5.81 x 106 cells/micro L Female: 3.91-5.11 x 106 cells/micro L
ESR
Male: Less than 50 yrs = 0-15 mm/hr More than 50 yrs = 0-20 mm/hr Female: Less than 50 yrs = 0-25 mm/hr More than 50 = 0-30 mm/hr
Normal hemoglobin
Males 12.69-17.4 Females 11.7-15.5
Normal hemocrit
Males 38-51% Females 33-45%
Tunneled Central Vascular Access Devices are a long or short term device?
provide long-term access to a central vein
Blood clots can disrupt the normal flow of blood to a part of the body, causing life-threatening conditions such as
pulmonary embolism or an acute stroke
A thrombectomy is an innovative surgical procedure used to
remove blood clots from arteries and veins. .
(Triple Lumen) Catheters extends into
superior vena cava
bleeding gums
systemic bleeding
bleeding within joints
systemic bleeding
blood in stool, urine, emesis
systemic bleeding
ecchymosis
systemic bleeding
excessive menstrual bleeding
systemic bleeding
frequent nosebleeds
systemic bleeding
petechiae
systemic bleeding
purpura
systemic bleeding
where something is wrong with the body; clotting is not working correctly.
systemic bleeding
Prevention of (CLABSI) Central Line Associated Bloodstream Infections?
1.Hand Hygiene - gloves 2.Maximal barrier precautions 3.Chlorhexidine skin antisepsis 4.Optimal catheter site selection 5.Daily assessment of central line necessity 6.Change dressing according to policy 7.Change Iv tubing at least every 96 hours according to policy 8.Scrub hub when accessing line
A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client's status after dialysis? 1. Vital signs and weight. 2. Potassium level and weight. 3. Vital signs and BUN. 4. BUN and creatinine levels.
1. Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.
2 ways that clotting becomes impaired?
1. clotting factors not available = excessive bleeding 2. clotting when not physiologically indicated = thrombus can impede blood flow
What are the 8 P's?
1. pulse 2. pallor 3. pain 4. palpated tense tissue 5. parastesthia 6. paralysis 7. paresis 8. poikilothermia
Magnesium (Mg2+)
1.7-2.2 mg/dL
What could the patient experience if they were having a bad reaction to blood?
1.Allergic reaction: flushing, rash, hives, anaphylactic rxn 2.Febrile, non hemolytic: chills, fever, HA 3.Septic: chills, vomiting, hypotension, fever 4.Circulatory overload: venous pressure, dyspnea, cough, crackles 5.Hemolytic reaction: low back pain, chills, tachycardia, hypotension, bleeding
Normal pathology for clotting 5 steps?
1.Injury resulting in bleeding 2.Vasoconstriction to reduce blood loss 3.Formulation of platelet plug 4.Clotting factors activated (intrinsic/extrinsic pathway) - coagulation cascade to common final pathway 5.Thrombin stimulates fibrinogen to form insoluble fibrin that stabilizes clot
Four components contribute to homeostasis;
1.Vascular response - constriction to press epithelial together and prevent leaking (20-30 min) 2.Platelet plug formation - platelets stick together and release clotting factors 3.Development of fibrin clot on platelet plug by clotting factors 4.Ultimate lysis of clot - fibrinolysis 5.Spleen stores platelets - patient with spleenectomy=increased platelets
Pro-time (PT)
10-13 seconds baseline 1.5-2x baseline on anticoagulation therapy
Spontaneous nosebleeds w/o trauma at platelet levels?
10-15,000
BUN/CRE ratio
10:1-20:1
Sodium Na+
135-145 mEq/L
BUN
14yrs-adult 8-21 mg/dL Greater than 90 yrs 10-31 mg/dL
•Once blood is initiated, must stay with client for at least how many minutes?
15
Platelets (thrombocytes)
150-450 x 103 cells/microL
A client has been admitted to the hospital for urinary tract infection an dehydration. The nurse determines that the client has received adequate volume replacement if the BUN drops to: 1. 3 mg/dL 2. 15 mg/dL 3. 29 mg/dL 4. 35 mg/dL
2. The normal blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options 3 and 4 reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.
What is the absolute low K+ can be?
2.5
Phosphorus (PO4)
2.5-4.5 mg/dL
How much of ICF are adults?
2/3
Activated Partial Thromboplastin Time (aPTT)
25-35 seconds baseline 1.5-2x baseline on anticoagulation therapy
The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of: 1. Pyelonephritits 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family
3. Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather pain would be in the flank area.
Glomerular filtration rate (eGFR)
90 or higher.
SpO2
95-100%
•Change IV tubing every? •Change needless end cap?
96 hours every 7 days
Chloride (Cl)
97-107 mEq/L
Potassium K+
3.5-5.3 mEq/L
Which patient has the highest risk for development of a blood clot? A: A woman who smokes and is taking estrogen-containing birth control pills B: A distance runner C: A man with a history of asthma D: A woman who is taking aspirin for menstrual cramps
A The combination of hormones and smoking may cause a hypercoagulability state. Distance running does not increase the risk of forming a blood clot. A patient with asthma does not predispose the formation of a blood clot. A patient taking aspirin will have a decreased risk of development of a blood clot due to the antiplatelet action of aspirin.
Hgb A1C
4.0-5.5%
WBC
4.5-11.1 x 103 cells/micro L
What are the S/S of venous/arterial clots?
5 p's Arterial: decreased pulse decreased hair decreased movement increased pain ulcers towards the tip of toes parathesis paralysis No or decreased blood flow: Venous: Valves not working, blood stasis. temp warm reddish-brown skin ulcers/ ankle wet appearance edema endoration/ hardness of vessels achy pain
How much ICF is older adults?
50-55%
How much of ICF are kids?
70%
Glucose
70-110 mg/dL
Calcium Ca+
8.6-10.2 mg/dL
Which interventions are most important for preventing bleeding in patients with bleeding disorders? Select all that apply. A: Using a soft-bristle toothbrush B: Avoiding over-the-counter medications that contain aspirin C: Using a blade razor D: Removing obstacles that may result in a fall E: Giving medication by intramuscular injection
A, B, D Use of a soft-bristle toothbrush decreases the trauma to the gums with oral care. Avoid the use of aspirin because of its antiplatelet effect. Decrease the fall risk to prevent bleeding from trauma. Do not use a blade razor because of the risk for nicks when shaving. Intramuscular injections are avoided in bleeding precautions due to the risk of bleeding into muscle from the trauma of the injection.
Hypophosphatemia
Caused by decreased absorption, excretion, and alcoholism S/S bone/muscle pain, chest pain, respiratory fx Treated with diet and IV
What is DIC?
Abnormal response of clotting cascade in response to a disease process or disorder. Can be acute/chronic. Has bleeding and thrombotic manifestations. Blood clots form throughout the body, blocking small blood vessels. clotting until use up all clotting factors - bleeding
What are risk factors of clotting?
Age - older adults - increased platelet adhesiveness, possible increase in clotting factors, Genetic - ie. Hemophellia (recessive genetic disorder - inability to produce adequate clotting factor), thrombocytopenia Immobility - slow down venous return, blood stagnant - sitting on long flights Smoking - hypercoagulability of blood Meds - anticoagulants
Hypovolemia interventions
Alarms Replace fluids Medications Monitor weight I+O
What is angioplasty?
An endovascular procedure that is used to widen narrowed or obstructed arteries or veins, in which a balloon catheter is passed over a wire into the narrowed location and then inflated to a fixed size. A stent may or may not be inserted at the time of balloon inflation to keep the vessel open. Used for arterial atherosclerosis typically.
What is an angiogram?
An x-ray that uses dye and a camera to take pictures of the blood flow in an artery or vein. Catheter placed in vessel at groin (femoral) or above elbow (brachial) and guided to area to be studied. Then iodine contrast is injected to visualize the area. Angiograms are used to diagnose coronary artery disease and to find aneurysms.
What is an Anticoagulant/ example?
Anticoagulants - prevents the formation of clots (Coumadin)
What is the antidote to Coumadin?
Antidote: teach vit K levels with coumadin - limit, will affect the PT/INR levels
What is an Antiplatelet example?
Antiplatelets - prevents any further clot process (Heparin) - platelets don't stick together
What are nursing interventions for arterial clots?
Arterial: Exercise - Collateral circ.- provides blood through small vessels Positioning - don't cross legs, dangle Promote vasodilation - No heating pad due to decreased feeling)/warm towel Control HTN No TED hose Avoid stress, smoking that constrict Avoid cold, caffiene
pH
Arterial: 7.35-7.45 Venous: 7.32-7.43
The nurse knows that which assessment finding is characteristic of a deep vein thrombosis in the leg? A:Bilateral edema of the leg associated with an albumin level of 2 g/dL B:Unilateral swelling with redness over the swollen area C:Risk reflexes in the lower extremities D:Brownish discoloration of the skin over the lower extremities
B A deep vein thrombosis of the leg may be associated with edema in the affected leg and erythema. Bilateral swelling of the legs associated with a low serum albumin level is related to decreased oncotic pressure. Brisk reflexes may be the result of a neurological disorder. Brownish discoloration of the lower extremities may be related to chronic venous insufficiency, not a deep vein thrombosis.
A patient is admitted to the medical unit with pneumonia. When reviewing home medications, which of the following medications would the nurse recognize as a risk for bleeding? A: Diltiazem (Cardizem) B: Warfarin (Coumadin) C: Acetaminophen (Tylenol) D: Metformin (Glucophage)
B Warfarin (Coumadin) is a medication that interferes with blood clotting by interfering with the vitamin K-dependent clotting factors. Diltiazem is a calcium channel blocker. Acetaminophen is an over-the-counter medication that does not interfere with blood clotting. Metformin is a medication used for diabetes.
Blood loss symptoms?
Blood loss symptoms: Lewis p. 643t Minor - none to syncope, fatigue Increased HR, decreased BV, orthostatic Hypotension Hypotension at rest, air hunger, rapid thread pulse, cold clammy skin progresses to Shock, acidosis, death Look at all systems: Bleeding: petechiae, ecchymosis, purpura, change in vital signs, brain, joints
What does Ca++ effect?
Bones, muscles, coagulation
What is the therapeutic level of INR? what is critical?
Book says 1.5-2 for INR, most facilities use 2-3 on therapy. Critical if above 4.5.
What would we administer hypertonic solution for?
Burns, trauma, loss of ECF
Implantable Ports are called?
Called Port-a-cath/Mediport
Can a patient be on both heparin and coumadin? How?
Can have both: come in on heparin IV with clot for immediate results. Then have coumadin to go home on. Takes 3-4 days for coumadin to work, wean heparin off when PT/INR levels are at therapeutic levels
How to care for DIC?
Care: treat the underlying problem, blood products, anticoagulation (heparin to preserve clotting factors that are present)
Central Venous Access Devices (CVAD) are what?
Catheters that are medically placed percutaneously through the chest wall into the jugular, subclavian, or into femoral vein.
Chlorhexidine skin antisepsis what to do?
Chlorhexidine skin antisepsis. Research shows that chlorhexidine provides better protection from infection than other antiseptic agents. It should be applied to the insertion site using a back-and-forth friction scrub for at least 30 seconds, and allowed to dry completely before the line is inserted.
What are Clinical manifestations of DIC?
Clinical manifestations: bleeding: hematomas, petechiae, purpura, tachypnea, orthopnea, GI bleeding, hematuria, vision changes, dizziness, headache, joint pain thrombotic; cyanosis, gangrene, necrosis, tachypnea, dyspnea, venous distention, abdominal pain, paralytic ileus, kidney damage, oliguria Blood in urine and stool, skin Organ failure
signs of arterial bleeding
Cold arm or leg. Decreased or no pulse in an arm or leg. Lack of movement in the arm or leg. Pain in the affected area. Numbness and tingling in the arm or leg. Pale color of the arm or leg (pallor) Weakness of an arm or leg.
What does osmolarity mean?
Concentration
CVAD blood draw from which port? (NS) 10cc -->
Connect 10cc NS syringe to proximal port, aspirate, flush forward, withdraw 5 cc blood for waste •Connect vacutainer, draw blood, remove •Flush with 20cc NS •Reconnect line or apply alcohol cap •On label write: date, time. Initial. Place in biohazard bad and send to lab.
Coumadin: therapeutic levels reach at? What test is used
Coumadin: therapeutic in 3-4 days INR was developed because PT times are often misleading and inconsistent. Most companies report both PT/INR.
A patient had a hip replacement 3 days ago. The patient states that the right leg is swollen below the knee and is warm to the touch. The patient has the diagnosis of deep vein thrombosis. Which intervention is appropriate for the patient? A: Massage the extremity to decrease pain. B: Place the leg in a dependent position. C: Apply ice bags to the lower leg. D: Elevate the right lower leg when the patient is in the sitting position.
D A patient with a deep venous thrombosis elevates the extremity when sitting or lying to enhance venous return to the heart. Massaging the extremity may dislodge a thrombus. If the leg is in the dependent position, blood return from the venous system will not be enhanced. Applying ice bags to the extremity may cause tissue injury.
Daily assessment of central line necessity, what's the goal?
Daily assessment of central line necessity. The goal here is to promptly remove lines that are no longer clearly needed for optimal care of the patient - and not to leave them in place for convenient access. The risk of infection increases over time as the line remains in place. (When central lines are placed for long-term use, as in chemotherapy, weekly review of necessity may be appropriate.)
What is DIC
DIC (disseminated Intravascular Coagulation) - excessive clot formation - when clotting factors all used up, will result in excessive bleeding
Implantable Ports are designed to?
Designed to permit repeated access to the venous system for administration of IV fluids, medications, nutritional solutions, and to obtain venous sampling
What are drug therapies for venous and arterial clots? 3 explain?
Drug therapy: Hemorheolic - Pentoxifylline (Trental) - allows RBC to change shape and be wriggly to get aroung plaque Antiplatelets - clopidogrel (Plavix)& Heparine, ASA - doesn't "thin" blood, doesn't let platelets stick together Control HTN - too low wont allow blood to pass plaque into tissue, too high - may burst plaque
Hypervolemia S/S
Edema, tachycardia, bounding pulse, hypertension, increased CVP, muscle weakness, confusion, weight fain, cradclkes, altered LOC, headahces
Embolism occurs when?
Embolism occurs when a piece of a blood clot, foreign object, or other bodily substance becomes stuck in a blood vessel and largely obstructs the flow of blood.
What would be administer isotonic solution for?
Excessive diarrhea, vomiting, shock, surgery, normal wear and tear Take caution with babies, elderly, renal fx
If blood or TPN is infusing in CVAD what does the nurse do? Lines with continuous meds?
Flush with 20 cc prior Lines with continuous meds infusing should not be interrupted - use another line if possible
Best way to prevent occlusion in CVAD? if unable then what?
Flushing most effective way to prevent occlusion 10 ml barrel to decrease pressure If unable to aspirate, have patient cough and try again. If still, may need activase
Hand hygiene requirements for CLABSI?
Hand hygiene. Hands should be washed before and after palpating insertion sites or accessing, replacing, or dressing a catheter.
Treatment for DIC is?
Heparin
Heprin test and coumadin test
Heprin PTT test and coumadin test PT
What does the nurse do when Heparin: PTT baseline 15, therap. 22.5-30, result 35?
Hold and call dr
What does the nurse do when Coumadin INR is 5.2? What about 1.2?
Hold and call dr INR 1.2 give and call dr to increase dose
What influences fluid balance?
Hormones (ADH, aldosterone, natriuretic peptides, Renin angiotensin II pathway
Implantable Ports use what to access the port?
Huber needle is used to access port . The skin is punctured each time the catheter is used.
What is the Virchows Triad?
Hyper-coagulation - imbalance of clotting mechanisms and clotting mechanism Vessel injury - release of clotting factors or activation of platelets Blood stasis - dysfunction of valves, immobility, unidirectional venous flow
What is fluid balance regulated by?
Hypothalamus, lymphatic, nueroendocrine, GI, renal (angiotensin II)
What does PO4 - - - effect?
ICF product of ATP, RBC, oxygen delivery
If a patient has a reaction to the blood?
If reaction: STOP transfusion immediately, notify physician Disconnect transfusion set Run Normal saline KVO on new line Place in Fowlers position. If Sob administer O2. Prepare emergency meds awaiting physicians order. Send bag and set to blood bank for repeat typing and culture Collect urine sample for hemoglobin determination
Hypovolemia S/S
Increased thirst, low output, skin tenting, hypothermia, tachycardia, hypotension, orthostatic hypotension, threaded pulse, dizzy, syncope, confusion, decreased CVP, nausea, constipation
Where is ECF?
Interstitial, intravascular, trans cellular, third spacing
What are invasive procedures for clots?
Invasive procedures: Percutaneous transluminal angioplasty (PTCA) Atheroectomy Thromboectomy Atherectomy - remove plaque PTCA - through tissue to inside of vessel and flattens plaque
Review dieretics, what does dieretics effect?
K+
Coumadin diet is supposed to avoid foods high in K+, what foods to AVOID?
Kale Spinach Brussels sprouts Collards Mustard greens Chard Broccoli Asparagus Green tea Cranberry juice Alcohol
Albumin to creatinine ratio (ACR)
Less than 30
Maximal barrier precautions involve what?
Maximal barrier precautions. One study found that the odds of developing CLABSI were six times higher when the line was placed without maximal barrier precautions. For the patient, these precautions involve covering the patient with a large sterile drape, with a small opening at the insertion site. For clinicians, it means using as mask, cap, sterile gown, and sterile gloves, the same as for surgical procedures. The best way to ensure compliance with this precaution is to keep all necessary equipment stocked together, to avoid the difficulty of hunting down supplies.
Magenesium
Mg 1.3-2.3 ICF cation Mg and K increase and decrease together Green leafy veg, nuts, peanut butter, coca, whole grains, seafood, laxatives (OTC meds)
Nursing considerations for patients with central lines
Minimize entries into the system, use strict aseptic technique when accessing, use needleless/luer-lock system, 30/30 rule. Never use excessive force when flushing, avoid syringes less than 3ml in size to decrease pressure on catheter (use 10ml instead), use slide clamps to prevent air embolism or blood backflow
What are the most common veins used in a Peripherally Inserted Central Catheter (PICC)?
Most common veins used are the basilic (largest), cephalic, and antecubital fossa veins
What does K+ affect?
Muscles, especially the heart
What does Mg effect?
Neuromuscular, cardiac, protein synthesis
Optimal catheter site selection, what is the best site? and the worst?
Optimal catheter site selection. Evidence-based guidelines recommend avoiding the femoral vein for catheter insertion in adult patients, as studies have shown this site correlates with higher infection rates. Some research indicates that use of the subclavian site correlates with lower infection rates than does the jugular insertion site.
How does fluid move?
Osmosis and diffusion
The patient selection for use of a Central Venous Access Devices (CVAD) for?
Patient selection for use: Long-term intravenous therapy Need for frequent venous access CVP monitoring Administration of total parenteral nutrition (TPN) Self-administration of intravenous therapies Sclerosed peripheral veins Limited peripheral venous access Irritating IV solutions
How is the interrelated concepts related to clotting? Perfusion Gas exchange IC regulation Mobility Pain Patient education
Perfusion - impaired when clots slowdown/stop blood flow, absence of clotting =hemorrhage Gas exchange - impaired when PE reduce pulmonary capillary blood available to carry O2 from aveloi to cells IC regulation - affected by clots or hemorrhage - stroke, hydrocephalus Mobility - risk for DVT Pain - Arterial thrombosis or constriction impairing perfusion to lower extremities, hemorrhage in joint space Patient education - management of disorders - prevention, management of bleeding
Implantable Ports are a long term therapy option with?
Resorvior slowly releases drug into blood stream Long-term therapy Low infection risk
What are the Risk Factors of DIC?
Risk factors p. 658t Common causes: sepsis, blood loss with trauma and surgery, burns, complications of pregnancy (abruptio placentae, eclampsia), transfusion reactions
Signs and symptoms of pulmonary embolism include:
Shortness of breath Pain with deep breathing Rapid breathing Increased heart rate
What rate should blood be started at?
Start infusion slowly at 10 gtt/min. then, if no reaction, run at ordered rate.
Central line dressing changes use?
Steril technique Chlorhexidine Air dry beforeapplication Infection caps Clamp to keep positive pressure and prevent an air embolism
Deep vein thrombosis may cause the following to occur around the area of a blood clot:
Swelling Pain or tenderness Increased warmth, cramps, or aching in the area that is swollen or painful, usually the calf or thigh Red or discolored skin
Venous bleeding distinctions are?
The blood is dark red, not bright like arterial bleeding. The blood flow is steady but not spurting; it can still be quick, though. The pressure is lower than arterial bleeding so it's usually easier to control.
Tunneled Central Vascular Access Devices location?
The tip is inserted into a central vein and advanced to the superior vena cava. The remainder of the catheter passes through a subcutaneous track and exits on the chest wall or abdomen for easy access
What does a Thrombolytic agent and Fibrinolytic do to a clot?
Thrombolytic agents - destroys the clot Fibrinolytics - breaks down the fibrin in clot (tPA)
Thrombosis occurs when?
Thrombosis occurs when a thrombus, or blood clot, develops in a blood vessel and reduces the flow of blood through the vessel.
What are the Types of blood products? 7
Types of blood products •Whole blood •Red blood cells •Fresh frozen plasma •Platelets •Albumin •Clotting factors •cryoprecipitate
What is the best way to diagnose a DVT?
Ultrasound
When flushing a CVAD what method is used?
Use push-pause method Clamp to keep positive pressure and prevent an air embolism Infection caps
Central Venous Access Devices (CVAD) are used for?
Used for: Fluid or blood administration Obtaining blood specimens Administering medications Administering parenteral nutrition Administer blood products
Venous bleeding happens in the?
Venous bleeding happens in the veins, which carry blood back to the heart.
What are the Three E's when relating to venous clots?
Venous: Three E's: Elastic (graduated compression stockings) Exercise Elevatio
What are nursing interventions for venous clots?
Venous: Three E's: Elastic (graduated compression stockings) Exercise Elevation Bed rest (not necessary) DO NOT MASSAGE the area (OK to gently palpate for induration) Monitor for signs of PE Drug Therapy
What does NA+ affect?
Water and brain
What does Cl- effect?
Water flow -> kidney cells
Explain hemophilia and what it looks like? X A B
X-linked recesive genetic disorder A: factor VIII deficiency B: Factor IX deficiency Prevent or treat bleeding, replace clotting factors,
Arterial clots PTCA, or percutaneous transluminal coronary angioplasty is
a minimally invasive procedure that opens blocked coronary arteries to improve blood flow to the heart muscle.
Blood is received from Blood Bank after being
being typed and cross-matched.
CLABSI is proven fatal between __ and __% are affected
between 12 and 25 percent of the patients affected
Capillary bleeding takes place in the?
capillaries, which are tiny blood vessels that connect the arteries to the veins.
When transfusion is completed,
close blood clamp and open saline to flush blood administration set. •Obtain final set vitals. •complete transfusion record and return designated portion of form to blood bank with empty blood bag (depending on facility).
Arterial clots
cold no pulse sharp achy pain numbness/tingling no hair growth
Nursing interventions
dangle legs; encourages perfusion in lower extremities warm linin; for warmth blood to feet not heart (NO TED) trentle- RBC change shape wiggle around clot no crossing legs
Hemophilia A=
factor 8 deficient
Hemophilia B=
factor 9 deficient
withdraw _ cc blood for waste in CVAD blood draw?
flush forward, withdraw 5 cc blood for waste •Connect vacutainer, draw blood, remove
Arterial bleeding occurs
in the arteries, which transport blood from the heart to the body.
bleeding at surgical site
localized bleeding
bleeding or ecchymosis at injury site
localized bleeding
caused by something else such as trauma.
localized bleeding
hematoma
localized bleeding
intracranial bleeding
localized bleeding
lacerations
localized bleeding
nosebleed if punched
localized bleeding
Informed consent must be signed?
prior to administering blood.
What are medical conditions that affect clotting?
thrombocytopenia - decrease in platelets=bleeding Hemophelia - genietic - defective or deficient coagulation factors - bleeding Polycythemia - increase in RBC = increase in thrombus formation Afib - blood stasis = clot formation
Venous clots
warm pulse dull pain no paralysis edematous valves in veins muscle contraction
INR
· Not on anticoagulation less than 2.0 · Receiving treatment for venous thrombosis, pulmonary embolism, and valvular heart disease 2.0-3.0 · Receiving treatment for mechanical heart valve 2.5-3.5
What are signs and symptoms of a blood reaction?
•*Chills •*Low back pain (kidneys) •Flushing •Headache •Rash •Chest or back pain •Nausea •Fever •Tachycardia •Respiratory distress •Hypotension
What are the 3 types of Central Venous Access Devices (CVAD)?
•3 types •Central catheters - Can be single, double, or triple lumen •Peripherally Inserted Central Catheter (PICC)- Can be double, triple, quadruple lumen (powerports) •Subcutaneously implanted ports (Port-a-Cath) - single or double port
What is Activated partial thromboplastin time (aPTT)? Normal levels and therapeutic levels?
•Activated partial thromboplastin time (aPTT) •Normal seconds 30-40 seconds •Anticoagulants (heparin ): 1.5-2 x normal
Complications of Central Venous Access Devices (CVAD)?
•Air embolism •Bleeding •Catheter occlusion/damage •Sepsis (CLABSI) •Hematoma •Hemothorax/pneumothorax •Phlebitis (usually from PICC)
What are different meds for clots?
•Anticoagulants •Antiplatelets •Direct thrombin inhibitors •Thrombolytic agents •Fibrinolytics
Excessive clotting: Arterial thrombosis what is the cause? 7
•Atherosclerosis from injury to arterial walls •HTN •Smoking •cholesterol •Increased platelet count, RBC production •Blocked - ischemia - death •Collateral circulation Think: The larger the vessel, the greater amount of tissue affected
Steps to administer Blood?
•Blood is received from Blood Bank after being typed and cross-matched. •Blood must be administered within 30 minutes after leaving Blood Bank. •Ask client about any allergies or previous reactions to blood transfusions. •Informed consent must be signed prior to administering blood. •Assess baseline vital signs, including temperature. •With another licensed nurse, compare blood and cross match slip and then data with client's ID band. •Serial number •Blood component •Blood type •Rh factor •Expiration date •Screening test for blood borne diseases •Check patient identification
•Blood must be administered within?
•Blood must be administered within 30 minutes after leaving Blood Bank.
Central Catheters (Triple Lumen) is what and when is it used?
•Catheter is percutaneously inserted through chest wall into internal jugular, subclavian, femoral veins (only used when other sites not available)
What is Cathflo Activase?
•Cathflo Activase IV medication used for treatment of a totally or partially occluded CVAD (must have order from primary care physician (PCP).
Changing needless end cap procedure?
•Change every 4 days •Clean gloves, mask •Flush line with 10 ml saline •Clamp and remove cap •Prime new cap with saline •Scrub junction •Attach new cap and aspirate and flush •clamp
Central Line Care when to change dressing?
•Changed at least every 7 days or when dressing is wet, peeling, dirty, etc.
What is the D-Dimer assess?
•D-Dimer - assesses activity of thrombin and plasmin •Fibrin byproducts when a clot is dissolved •Confirms a diagnosis of DIC
Peripherally Inserted Central Catheter (PICC) also called midline catheters diameter is? Available in?
•Diameter 23g-16g catheters ,length 16-24 inches •Available in single, double, and triple lumens
Where does Fibrinogen (CF I) occur and what is the normal of adults and newborns?
•Fibrinogen (CF I) •Occurs in liver disease, malnutrition, DIC •Normal adults 200-400 mg/dl, newborns 125-300 mg/dl (low=bleeding)
After blood draw of CVAD is complete what does the nurse do?
•Flush with 20cc NS •Reconnect line or apply alcohol cap •On label write: date, time. Initial. Place in biohazard bad and send to lab.
CVAD Med administration and flushing
•Hand hygiene •cleanse cap with antimicrobial swap •unclamp line •attempt to aspirate for presence of blood •flush with 10ml of Normal Saline (NS). •Reclamp catheter. •Flushing before/after administration of TPN or blood, or after obtaining blood specimens is 20 ml of NS •Document
What is International normalized ratio (INR)? Normal levels and therapeutic levels?
•International normalized ratio (INR) •Standardized measurement. Normal 1.5-2 •On therapy: 2-3 (CV/PE 3.4-5)
Implantable Ports are what?
•Light weight, durable titanium reservoir, permanent device that consists of a catheter attached to a small reservoir, both of which are placed under the skin. The catheter is placed completely under the skin. Huber needle is used to access port . The skin is punctured each time the catheter is used.
Peripherally Inserted Central Catheter (PICC) is a long catheter ___?
•Long catheter extends from an arm vein into the superior vena cava
How long can a Peripherally Inserted Central Catheter (PICC) be in place?
•May remain in place for weeks to several months
PICC line when to change dressing?
•PICC: 48 hours after initial insertion and then every 7 days •Assess for redness, swelling, discharge. Document every 4 hours.
What is the normal Platelet count of adults/children and newborns?
•Platelet count •Normal adults and children 150,000-400,000 per mm3, newborns 150,000-300,000, infants 200,000-475,000
Treatment of bleeding?
•Pressure •Ice •Volume replacement •Replacement of factors •Replacement of platelets
What is Prothrombin time (PT)? Normal levels and therapeutic levels?
•Prothrombin time (PT) - measures clotting factors. When the value is higher, more time is needed before clots •Normal 11-12.5 seconds •On Coumadin: therapeutic level 1.5-2.5 x normal (baseline)
Other diagnostic tests to detect clots are? 5
•RBC count, Hgb, Hct - elevated counts show polycythemia (Blood cancer to many) •Bone marrow exam •Arteriograms •Venograms •Ultrasounds (to see how narrow arteries are inject contrast into the arterial system monitor femoral site vitals )BP/HR - look for bleeding)
Why do patients experience inadequate clotting factors?
•Reasons: •Liver disease: liver doesn't produce clotting factors •Hemophilia: genetic, decreased clotting factors •Von Willebrands Disease - genetic
With another licensed nurse, compare blood and cross match slip and then data with client's ID band. Check information?
•Serial number •Blood component •Blood type •Rh factor •Expiration date •Screening test for bloodborne diseases •Check patient identification
Health Promotion of clotting?
•Teach signs and symptoms of bleeding •Minimize risk for trauma - use a soft bristle brush, electric razor, no tatoos or piercing, watch menstruation •No ASA
Tunneled Central Vascular Access Devices common types?
•Three common types: •Hickman •Broviac •Groshong Special types - Hickman (clamps), Groshong (valve)
•Thrombocytopenia - platelets levels? normal, significant, risky?
•Thrombocytopenia - platelets less than 150,000/mm3 - significant if falls below 100,000 •Risk for hemorrhage 50,000
Central line care facts!?
•Trained RN only •Changed at least every 7 days or when dressing is wet, peeling, dirty, etc. •PICC: 48 hours after initial insertion and then every 7 days •Assess for redness, swelling, discharge. Document every 4 hours. •Change IV tubing every 96 hours •Change needless end cap every 7 days
CVAD blood cultures procedure?
•Use aseptic technique •Label bottle properly •Do not flush prior or discard with blood cultures •Inject in bottles: 8-10 ml •BACTEC Aerobic bottle •BACTEC Lytic Anerobic bottle •Flush with 20 ml NS •Document time blood culture was obtained
Do you warm blood before administering it?
•Warm blood before administration to prevent chills.
CVAD Blood draw procedure?
•Wash hands and put on gloves •Place infusion on hold for at least a min. and cap line •Scrub hub for 15 seconds, allow to dry •Connect 10cc NS syringe to proximal port, aspirate, flush forward, withdraw 5 cc blood for waste •Connect vacutainer, draw blood, remove •Flush with 20cc NS •Reconnect line or apply alcohol cap •On label write: date, time. Initial. Place in biohazard bad and send to lab.
What type of tubing does blood use? what goes on the end of it?
•Y-shaped blood tubing used. (date/time label on tubing.) •500 ml Normal Saline attached to one end of Y •Saline used to prime the tubing (both arms of the Y) and start saline infusion.
Phosphorus
PO4 - - - 2.5- 4.5 mg/dl Inversely proportional to Ca++ Primary anion of ICF Acid base balance, nuero, muscle function, energy transfer of ATP, metabolism of carbs, lipids, protein, vitamin D synthesis, found in bones. Milk, nuts, grains, dry fruits/vegs, poultry
Types of Central Venous Catheters (CVC)
Peripherally Inserted Central Catheter (PICC), Tunneled CVC, Implanted port, Dialysis catheter, Nontunneled CVC
Permanent Dialysis Catheters
Permacath, tunneled dialysis catheter. More strict qualifications required for placement.
A client has developed acute renal failure (ARF) as a complication of glomerulonephritis. The nurse assesses the client for which of the following as an expected manifestation of ARF? 1. Hypertension 2. Bradycardia. 3. Decreased cardiac output 4. Decreased central venous pressure
1. ARF caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of ARF is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. ARF from prerenal causes is characterized by decreased blood pressure, or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for any form of renal failure.
The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the menu? 1. Cream of wheat, blueberries, coffee 2. Sausage and eggs, banana, orange juice. 3. Bacon, cantaloupe melon, tomato juice. 4. Cured pork, grits, strawberries, orange juice.
1. The diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Options 2, 3, and 4 are high in sodium, phosphorus and potassium.
The nurse monitoring a client receiving peritoneal dialysis notes that the clietn's outflow is less than the inflow. Select all nursing actions in the situation that apply. 1. Contact the physician. 2. Check the level of the drainage bag. 3. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.
2, 3, 4, 5. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Increasing the flow rate is an inappropriate action and is not associated with the amount of outflow solution.
Air embolism
A complication of central catheters that occurs when intrathoracic pressure becomes less than atomastpheric pressure when the catheter is open to air. Air enters the vein. signs and symptoms include sudden respiratory distress, tachypnea, cyanosis, chest pain.
Complications of Central Venous Catheters
Pneumothorax, bloodstream infecitons, thrombosis, misplacement, air embolism, hemorrhage, hematoma
Hypocalcemia
Caused by low intake of Ca++ and vitamin D, loop dieretics, low PTH, renal fx, malabsorption S/S EKG changes, muscle cramps in fingers, tetany, seizures Treated with diet, meds, IV therapy
Arterial Line
Inserted in artery for monitoring and blood draws. Never injected, attached to pressure bag. Inserted by physician or certified RN.
A nurse is reviweing the medication record of a client diagnosed with chronic renal failure (CRF). The nurse notes that the client is receiving aluminum hydroxide (Amphojel). The nurse determines that the purpose of this medication is to: 1. Combine with phosphorus and help eliminate phosphates from the body. 2. Prevent ulcers. 3. Promote the elimination of potassium from the body. 4. Prevent constipation
1. Aluminum hydroxide binds with phosphate in the intestines for excretion in the feces, thus lowering phosphorus levels. It can cause constipation, and it does not promote the elimination of potassium. It may be used in the treatment of hyperacidity associated with gastric ulcers, but this is not the purpose of its use in the client with renal failure.
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 providone-iodine.
1. Clients with peritoneal dialysis catheters are at high risk for infection. A wet dressing is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.
What is therapeutic embolization?
A nonsurgical, minimally-invasive procedure performed by interventional radiologists which involves the selective occlusion of blood vessels by purposely introducing emboli to block the vessel. Used to stop hemorrhage in recurrent hemoptysis, AVMs, cerebral aneurysms (hemorrhagic stroke), GI bleed, epistaxis, varicocele (enlargement of veins in scrotum), primary post-partum hemorrhage, surgical hemorrhage, and uterine fibroids. Also used to stop tumor growth in kidney lesions, liver lesions (esp. hepatocellular carcinoma), and uterine fibroids.
Trousseau's Sign
A sign of hypocalcemia. Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.
Catheter embolism
Complication of central cathters that occurs when the catheter is pulled back and sheared off through inserting needle or from catheter rupture. Signs and symptoms include chest pain and cardiac dysrhythmias.
Nursing Responsibilities before the patient is sent to Interventional Radiology
Ensure that consent form is signed for the procedure, if necessary. Keep NPO. Establish functional IV access. Check with MD before giving any anticoagulant meds. Draw labs: PT, PTT, platelets, BUN/Creatinine, WBC (if necessary for procedure)
Chvostek's Sign
Hypocalcemia (facial muscle spasm upon tapping)
The client with urolithiasis has a history of chronic urinary tract infections. The nurse plans teaching the client to avoid which of the following? 1. Long-term use of antibiotics. 2. Wearing synthetic underwear and pantyhose. 3. High--phosphate foods, such as dairy products. 4. Foods that make the urine more acidic, such as cranberries.
2. Urolithiasis (struvite stones) can result from chronic infections. They form in urine that is alkaline and rich in ammonia, such as with a urinary tract infection. Teaching should focus on prevention of infections and ingesting foods to make the urine more acidic. The client should wear cotton (not synthetic) underclothing to prevent the accumulation of moisture and to prevent irritation of the perineal area, which can lead to infection.
Calcium
Ca++ 8.6-10.2 mg/dl Inverse relationship with phosphorus Controlled by PTH, calcitonin, and vitamin D Low albumin can result is low total calcium Nerve transmission, b12 absorption, bone/teeth, muscle contraction, blood clotting Found in dairy, broccoli, spinach, sardines, and salmon
A registered nurse is instructing a new nursing graduate about hemodialysis. Which statement if made by the new nursing graduate would indicate an inaccurate understanding of the procedure for hemodialysis? 1. Sterile dialysate must be used. 2. Warming the dialysate increases the efficiency of diffusion. 3. Heparin sodium is administered during dialysis. 4. Dialysis cleanses the blood from accumulated waste products.
1. Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile. The dialysate is warmed to approximately 100° F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Heparin sodium inhibits the tendency of blood to clot when it comes in contact with foreign substances. Option 4 is the purpose of dialysis.
A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which of the following lab tests? 1. Partial thromboplastin time (PTT) 2. Prothrombin time (PT) 3. Thrombin time (TT) 4. Bleeding time
1. Heparin is the anticoagulant used most often during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by checking the PTT, which is the appropriate measure of heparin effect. The PT is used to monitor the effect of warfarin (Coumadin) therapy. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities.
Following a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. The nurse interprets this complaint and further assesses the client for: 1. Bleeding. 2. Infection. 3. Renal colic. 4. Bladder perforation.
1. If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit level, and gross or microscopic hematuria also would indicate bleeding. Signs of infection would not appear immediately following a biopsy. The biopsy site would be the flank area and not the lower abdomen. No data are given to support the presence of renal colic.
The client being 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 embolus.
1. If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed. Options 2, 3, and 4 are incorrect.
A nursing student is assigned to care for a client with a diagnosis of acute renal failure, diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which of the following statements if made by the nursing student would indicate an adequate understanding of the treatment plan for this client? 1. Prevent loss of electrolytes. 2. Reduce the urine specific gravity. 3. Promote the excretion of wastes. 4. Prevent fluid overload
1. In the diuretic phase, fluids and electrolytes are lost in the urine. As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. Options 2, 3, and 4 are not the primary concerns in this phase of renal failure.
A nurse is giving general instructions to a client receiving hemodialysis. Which of the following statements would be appropriate for the nurse to include? 1. Several types of medications should be withheld on the day of dialysis until after the procedure. 2. Medications should be double-dosed on the morning of hemodialysis to prevent loss. 3. It's acceptable to exceed the fluid restriction on the day before hemodialysis. 4. It's acceptable to eat whatever you want on the day before hemodialysis.
1. Many medications are dialyzable, which means they are extracted from the bloodstream during dialysis. Therefore, many medications may be withheld on the day of dialysis until after the procedure. It is not typical for medications to be "double-dosed," because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions.
The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the following would be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? 1. Maintain strict aseptic technique. 2. Add heparin to the dialysate solution. 3. Change the catheter site dressing daily. 4. Monitor the client's level of consciousness.
1. The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although option 3 may assist in preventing infection, this option relates to an external site. Options 2 and 4 are unrelated to the major complication of peritoneal dialysis.
A nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula. 2. Presence of a radial pulse in the left wrist. 3. Absence of a bruit on auscultation of the fistula. 4. Capillary refill less than 3 seconds in the nail beds of the fingers of the left hand.
1. The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill shorter than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.
A client with chronic renal failure has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse interprets that these assessment data are compatible with: 1. Phosphate overdose 2. Aluminum intoxication 3. Advancing uremia 4. Folic acid deficiency
2. Aluminum intoxication can occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.
The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of: 1. Infection. 2. Hyperglycemia. 3. Hypophosphatemia. 4. Disequilibrium syndrome.
2. An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.
The client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse asks the client if the pain is referred to which of the following area? 1. Hip 2. Shoulder 3. Umbilicus 4. Costovertebral angle
2. Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders. Bladder injury pain does not radiate to the umbilicus, costovertebral angle, or hip.
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? 1. Monitor the client. 2. Notify the physician. 3. Elevate the head of the bed. 4. Medicate the client for nausea.
2. Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified.
Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following? 1. It is used to lower your blood pressure. 2. It is used to treat anemia. 3. It will help to increase the potassium level in your body. 4. It is an anticonvulsant medication given to all clients after dialysis to prevent seizure activity.
2. Epoetin alfa is a medication that is used to treat anemia. Options 1, 3, and 4 are incorrect. Hypertension is a side effect. Hyperkalemia and seizures are adverse effects of the medication.
A client undergoing hemodialysis has an arteriovenous (AV) fistula in the left arm. A related nursing diagnosis for the client is risk for infection. The nurse should formulate which of the following outcome goals as most appropriate for this nursing diagnosis? 1. The client's temperature remains less than 101F 2. The client's WBC count remains within normal limits. 3. The client washes hands at least once per day. 4. The client states to avoid blood pressure measurement in the left arm.
2. General indicators that the client is not experiencing infection include a temperature and WBC count within normal limits. The client also should use proper hand-washing technique as a general preventive measure. Hand washing once per day is insufficient. It is true that the client should avoid BP measurement in the affected arm; however, this would relate more closely to the nursing diagnosis risk for injury.
A client diagnosed with polycystic kidney disease has been taught about the treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes: 1. Genetic counseling. 2. Sodium restriction. 3. Increased water intake. 4. Antihypertensive medications.
2. Individuals with polycystic kidney disease seem to waste rather than retain sodium. Thus, they need increased sodium and water intake. Aggressive control of hypertension is essential. Genetic counseling is advisable because of the hereditary nature of the disease.
The nurse is reviewing the client's record and notes that the physician has documented that the client has a renal disorder. On review of the lab results, the nurse most likely would expect to note which of the following? 1. Decreased hemoglobin level. 2. Elevated BUN 3. Decreased red blood cell count. 4. Decreased white blood cell count.
2. Measuring the blood urea nitrogen level is a frequently used laboratory test to determine renal function. The blood urea nitrogen level starts to rise when the glomerular filtration rate falls below 40% to 60%. A decreased hemoglobin level and red blood cell count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased white blood cell count is most likely to be noted in renal disease.
A client is admitted to the hospital with a diagnosis of early-stage chronic renal failure. Which of the following should the nurse expect to note on client assessment? 1. Anuria. 2. Polyuria. 3. Oliguria. 4. Polydypsia.
2. Polyuria occurs early in chronic renal failure and, if untreated, can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal kidney functions. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal failure.
The hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse assesses this client for which of the following manifestations? 1. Warmth, redness, and pain in the left hand. 2. Pallor, diminished pulse, and pain in the left hand. 3. Edema and reddish discoloration of the left arm. 4. Aching pain, pallor, and edema of the left arm.
2. Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth, redness, and pain probably would characterize a problem with infection. The manifestations described in options 3 and 4 are incorrect.
The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse would plan which of the following as a priority action? 1. Check the sodium level. 2. Place the client on a cardiac monitor. 3. Encourage increased vegetables in the diet. 4. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration.
2. The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse.
The client who has a history of gout also is diagnosed with urolithiasis and the stones are determined to be of uric acid type. The nurse gives the client instructions in which foods to limit, including: 1. Milk 2. Liver 3. Apples 4. Carrots
2. The client with uric acid stones should avoid foods containing high amounts of purines. This includes limiting or avoiding organ meats such as liver, brain, heart, kidney, and sweetbreads. Other foods to avoid include herring, sardines, anchovies, meat extracts, consommés, and gravies. Foods that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, sugars and sweets, coffee, tea, chocolate, and carbonated beverages.
The client who has suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse assesses this particular client carefully for signs of: 1. Brain attack (stroke) 2. Acute tubular necrosis 3. Respiratory failure 4. Myocardial infarction
2. The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream, where it is cleared from the body by the kidneys. When there is a large amount of myoglobin being cleared from the body, there is a risk of the renal tubules being clogged with myoglobin, causing acute tubular necrosis. This is one form of acute renal failure.
A client with chronic renal failure is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of hemodialysis treatments. The nurse's response is based on an understanding that the typical schedule is: 1. 5 hours of treatment 2 days per week. 2. 3 to 4 hours of treatment 3 days per week 3. 2 to 3 hours of treatment 5 days per week 4. 2 hours of treatment 6 days per week
2. The typical schedule for hemodialysis is 3 to 4 hours of treatment three days per week. Individual adjustments may be made according to variables such as the size of the client, type of dialyzer, the rate of blood flow, personal client preferences, and others.
Hypomagnesiemia
Caused by GI loss, alcoholism, starvation Treated by diet changes, IV, meds (Symptoms are opposite prefix)
Hyperkalemia
Caused by excessive intake or trauma S/S muscle weakness, arrhythmias, N/V Monitor EKG Treatment is remove from diet, dialysis, medication
Chloride
Cl- 97-107 Mostly from salt we eat, tomato's, leafy greens, olives, seaweed, rye bread Maintains fluid balance
A nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements if made by the client indicates an accurate understanding of CAPD? 1. A portable hemodialysis machine is used so that I will be able to ambulate during the treatment. 2. A cycling machine is used so the risk for infection is minimized. 3. No machinery is involved, and I can pursue my usual activities. 4. The drainage system can be used once during the day and a cycling machine for 3 cycles at night.
3. CAPD closely approximates normal renal function, and the client will need to infuse and drain the dialysis solution several times a day. No machinery is used, and CAPD is a manual procedure.
The nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response on knowing that the glucose: 1. Decreases the risk of peritonitis. 2. Prevents disequilibrium syndrome. 3. Increases osmotic pressure to produce ultrafiltration. 4. Prevents excess glucose from being removed from the client.
3. Increasing the glucose concentration makes the solution more hypertonic. The more hypertonic the solution, the higher the osmotic pressure for ultrafiltration and thus the greater the amount of fluid removed from the client during an exchange. Options 1, 2, and 4 do not identify the purpose of the glucose.
The nurse is caring for the client who has undergone renal angiography using the left femoral artery for access. The nurse determines that the client is experiencing a complication of the procedure if which of the following is observed? 1. Urine output, 50 mL/hr 2. Blood pressure, 110/74 mm Hg 3. Pallor and coolness of the left leg. 4. Absence of hematoma in the left groin.
3. Potential complications after renal angiography include allergic reaction to the dye, renal damage from the dye, and vascular complications, which include hemorrhage, thrombosis, or embolism. The nurse detects these complications by noting signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and/or signs of decreased circulation to the affected leg.
A nurse is working with the client newly diagnosed with chronic renal failure (CRF) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse assesses that the client is exhibiting: 1. Withdrawal 2. Depression 3. Anger 4. Projection
3. Psychosocial reactions to CRF and hemodialysis are varied and may include anger. Other reactions include personality changes, emotional lability, withdrawal, and depression. The individual client's response may vary depending on the client's personality and support systems. The client in this question is exhibiting anger. The client has not projected blame on the nurse, nor does the client statement reflect withdrawal or depression.
The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2F. Which of the following is the appropriate nursing action? 1. Encourage fluids. 2. Notify the physician. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection.
3. The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations.
The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information if the client states to record daily the: 1. Amount of activity. 2. Pulse and respiratory rate. 3. Intake and output and weight. 4. Blood urea nitrogen and creatinine levels.
3. The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight/day.
A client diagnosed with chronic renal failure (CRF) is scheduled to begin hemodialysis. The nurse assesses that which of the following neurological and psychosocial manifestations if exhibited by this client would be unrelated to the CRF? 1. Labile emotions. 2. Withdrawal. 3. Euphoria. 4. Depression.
3. The client with CRF often experiences a variety of psychosocial changes. These are related to uremia, as well as the stress associated with living with a chronic disease that is life-threatening. Clients with CRF may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation. Delusions and psychosis also can occur. Euphoria is not part of the clinical picture for the client in renal failure.
An adult client has had lab work done as part of a routine physical exam. The nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted? 1. 0.2 mg/dL 2. 0.5 mg/dL 3. 1.9 mg/dL 4. 3.5 mg/dL
3. The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slightly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatinine level of 3.5 mg/dL may be associated with acute or chronic renal failure.
A nurse tests the urine of a client with acute renal failure (ARF) with a multitest reagent strip. The strip tests highly positive for proteinuria. The nurse analyzes that this result is consistent with which of the following types of renal failure? 1. Atypical renal failure 2. Prerenal failure 3. Intrinsic renal failure 4. Postrenal failure
3. With intrinsic renal failure, there is a fixed specific gravity and the urine tests definitely positive for proteinuria. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. There is no disorder known as atypical renal failure.
What is a CT scan?
Computerized Tomography. Series of many x-ray images taken from different angles to produce cross-sectional (tomographic) images of specific areas, allowing the user to see inside the body without surgery. CTs can be used with oral contrast, IV contrast, both, or neither. They emit high radiation, however they are the gold standard for diagnosing many conditions.
The client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The priority nurse action would be to: 1. Check the shunt for the presence of bruit and thrill. 2. Observe the site once as time permits during the shift. 3. Check the results of the prothrombin times as they are determined. 4. Ensure that small clamps are attached to the arteriovenous shunt dressing.
4. An arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours.
A client is schedule for a excretory urogram. Which of the following would the nurse expect to be prescribed as a component of preparation for this test? 1. NPO status after midnight. 2. Administration of a sedative before the test. 3. Administration of intravenous fluids. 4. Bowel preparation to remove fecal contents.
4. An excretory urogram is an invasive test that uses contrast radiopaque dye to assess the ability of the kidneys to excrete dye in the urine. Bowel preparation is necessary to permit adequate visualization of the kidneys, ureters, and bladder. Options 1, 2, and 3 usually are not components of preparation for this test.
The client with chronic renal failure 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 from dialysis.
4. Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting an entire day to resume the medication. This would lead to ineffective control of the blood pressure.
A nurse is caring for a client with acute renal failure (ARF). When performing an assessment, the nurse would expect to note which of the following breathing patterns? 1. Decreased respirations. 2. Apneic 3. Cheyne-Stokes 4. Kussmaul's
4. Clinical manifestations associated with ARF occur as a result of metabolic acidosis. The nurse would expect to note Kussmaul's respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon dioxide. Options 1, 2, and 3 are not characteristic of ARF.
The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: 1. Hypertension, tachycardia, and fever. 2. Hypotension, bradycardia, and hypothermia. 3. Restlessness, irritability, and generalized weakness. 4. Headache, deteriorating level of consciousness, and twitching.
4. Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.
The nurse develops a postprocedure plan of care for a client who had a renal biopsy. The nurse avoids documenting which intervention in the plan? 1. Administering analgesics as needed. 2. Encouraging fluids to at least 3 L in the first 24 hours. 3. Testing serial urine samples with dipsticks for occult blood. 4. Ambulating the client in the room and hall for short distances.
4. Following renal biopsy, the nurse ensures that the client remains in bed for at least 24 hours. Vital signs and puncture site assessments are done frequently during this time. Encouraging fluids is done to reduce possible clot formation at the biopsy site. Serial urine samples are assayed by Hematest with urine dipsticks to evaluate bleeding. Analgesics often are needed to manage the renal colic pain that some clients feel after this procedure.
A nurse is analyzing the posthemodialysis lab test results for a client with chronic renal failure (CRF). The nurse interprets that the dialysis is having an expected but nontherapeutic effect if the results indicate a decreased: 1. Phosphorus. 2. Creatinine. 3. Potassium. 4. Red blood cell count
4. Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. Hemodialysis also worsens anemia, because RBCs are lost in dialysis from blood sampling and anticoagulation during the procedure, and from residual blood that is left in the dialyzer. Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process.
A client newly diagnosed with renal failure has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate? 1. Stop the dialysis. 2. Slow the infusion. 3. Decrease the amount to be infused. 4. Explain that the pain will subside after the first few exchanges.
4. Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.
A client newly diagnosed with chronic renal failure (CRF) has many learning needs regarding the disease. The nurse prepares a teaching plan to help the client adapt to the disease. The nurse recognizes that which of the following client characteristics or factors is least likely to interfere with the client's ability to learn? 1. Anxiety. 2. Memory deficits. 3. Short attention span. 4. Presence of family.
4. The client with CRF may have several barriers to learning. Anxiety about the disease and its ramifications frequently may interfere with learning. Physiological effects of the disease process also impair the client's mental functioning. Specifically, the client may exhibit a short attention span and have memory deficits. Mental functioning usually improves once hemodialysis has begun. The presence of family members is helpful because they need to understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over.
The nurse has taught the client with polycistic kidney disease about management of the disorder and prevention and recognition of complications. The nurse determines that the client understands the instructions if the client states that there is no reason to be concerned about: 1. Burning on urination. 2. A temperature of 100.6F 3. New-onset shortness of breath. 4. A blood pressure of 105/68 mmHg
4. The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection so that treatment may begin promptly. Lowered blood pressure is not a complication of polycystic kidney disease, and it is an expected effect of antihypertensive therapy. The client would be concerned about increases in blood pressure because control of hypertension is essential. The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, are also a concern.
Potassium
K+ 3.5-5.3 mEq/l Main ICF cation Inversely proportional to sodium (potassium up, sodium down) Nerve contraction, regulates enzyme Regulated by kidney 40-60 mEq/ day recommended Found in bananas, cantaloupe, citrus, green leafy vegs, avocado, molasses
A client with chronic renal failure (CRF) is on fluid restriction. The client is fatigued and therefore has a limited tolerance for activity. The client takes aluminum hydroxide gel (Alternagel) as a phosphate binder. On the basis of this information, the nurse determines that the client is most at risk for which of the following nursing diagnoses? 1. Impaired physical mobility. 2. activity intolerance. 3. Deficient fluid volume. 4. Constipation.
4. The client with renal failure is almost certain to have a problem with constipation as a result of factors such as fluid restriction, fatigue that limits exercise, and dietary restrictions. In addition, phosphate-binding antacids such as aluminum hydroxide gel cause constipation as a side effect.
A client is undergoing diagnostic tests to rule out a diagnosis of renal disease. The lab results indicate a ratio of BUN to creatinine of 15:1. The nurse determines that this result indicates: 1. A fluid volume deficit 2. Liver failure 3. A fluid volume excess 4. A normal ratio
4. The normal ratio of BUN to creatinine is approximately 10:1 to 15:1. A value lower than 10:1 would indicate diminished urea concentration. A value greater than 15:1 would indicate inadequate renal function.
Peripherally Inserted Central Catheter
A central venous catheter inserted via a peripheral vein in arm (such as basilica or cephalic). Catheter tip rests in the superior vena cava. Placement must be verified with x-ray. 1-3 ports, low infection rates. PICCs used to administer medications, antibiotics, and for monitoring.
Reasons for use of central lines
Long-term IV antibiotics, long term parenteral nutrition, long-term medications, chemotherapy, caustic drugs that would cause phlebitis in peripheral veins (calcium chloride, chemo, hypertonic saline, KCl, amiodarone, vasopressors(epinephrine, dopamine)), plasmapheresis, peripheral blood stem cell collections, dialysis, frequent blood draws, other frequent or persistent requirement for IV access, need for IV therapy when peripheral venous access is impossible, monitoring central vnous pressure in acutely ill patients to quantify fluid balance.
Sodium
NA+ Found in salt, broth, soda, baking soda 135-145 mEq/l Main ECF cation Water follows Most common imbalance because it is most abundant in ECF Needed for muscle movement and nerve impulses
Swan-Ganz Catheter
Nontunneled percutaneous pulmonary artery catheter inserted via jugular, subclavian (rare) or femoral vein. Tip rests in pulmonary artery. has multiple lumens for CVP (central venous pressure), PA (pulmonary aretery prsssure,) and IV ports for fluid.
Complications of arterial lines
Occlusion of catheter, occlusion of artery, inaccurate monitoring, malpositioning
Tunneled Central Venous Catheter (Power Line)
Fairly new to practice. Passed under the skin from the insertion site to a separate site. Catheter and attachments emerge from underneath the skin. Exit site is typically located in the chest, making the access ports less visible than catheters that protrdude directly from the neck.
Nontunneled Central Venous Catheter
Fixed in place at the site of insertion, with the catheter and attachments protruding directly (ex: Quinton catheter). Large in diameter with multiple lumens. Can be in jugular, subclavian, or femoral vein. The catheter tip rests in the superior vena cava or right atrium (except femoral). Needs to be verified with chest x-ray.
Implanted Port
Similar to tunneled catheter, but left entirely under the skin. Inserted into subclavian or jugular vein, with catheter tip resting in the superior vena cava. Medications are injected through the skin into the catheter. Access by special needle. Some implanted ports contain a small reservoir which can be filled and then slowly release the medication into the bloodstream. Less obvious than tunneled catheter and requires little daily care. Lower infection rates.
Temporary Dialysis Catheters
Type of Central Venous Catheter for dialysis only (unless the patient is coding-then can be used as main central line access). Two ports: blood from the red port travels to the dialysis machine and then is returned to the patient via the blue port.
IV Contrast
Used in some CT scans. Purpose is to visualized blood vessels and differentiate between anatomy. Must ask about allergies and draw BUN/Creatinine for kidney function before giving to the patient. Also note type of IV present: 18 gauge to 20 gauge needed because contrast is thick.
What types of procedures do IR (interventional radiology) do?
angiograms, specialized IV placement, embolizations (coils or glue), stenting, angioplasty, stroke intervention, thrombolysis, catheters/tubes for dialysis or gastrostomy.
Most common complication of PICC
phlebitis: mechanical irritation or injry to vein wall
