Elevate Q-Cards Module 2 Cardiac & Renal

Hemodialysis

1. 3-4x a week 2. Hold nitro, Water soluble vitamins, and Ampicillin

CAPD Peritoneal Dialysis

1. 4 times a day/ 7 days a week 2. Not for pts with arthritis or colostomy

What can decrease cardiac output?

1. A decreased heart rate. 2. Arrhythmias: Pulseless V-Tach, V-Fib, Asystole. We are scared of these arrhythmias because you have no cardiac output with these arrhythmias. People tend to be dead when they have these arrhythmias because they have no cardiac output.

Heart Failure (Treatment)

1. ACE Inhibitors -Suppress RAS -Dilation and Increases SV 2. ARB's -Decreases resistance and BP 3. Digoxin 4. Diuretics 5. Low Sodium diet 6. Elevate Head of Bed 7. Report weight gain of 2-3 lbs 8. Pacemaker

S/S in Acute Kidney Injury

1. Anemia; decreased erythropoietin. 2. Hypertension; retaining fluid and increased workload of the heart. 3. Itching Frost; urea excess is surfacing to the skin. 4. FVE/HF; kidneys aren't working, so fluid in the vascular will continue to increase. The kidneys can't filter out excess fluid.

HF (Diagnosis)

1. BNP is secreted when pressures in the heart are increased -Turn off nesiritide 2 hours before drawing a BNP 2. CXR 3. Echo

Common symptoms of the oliguric phase of acute renal injury:

1. BUN and Creatinine level: Increase in renal failure. 2. Urine specific gravity: Increases in renal failure. They're putting out, if they're putting out any urine at all, it's either concentrated or it has a fixed specific gravity---so the urine specific gravity goes up. 3. Potassium level: Increases in renal failure because the kidneys aren't filtering well or excreting much urine. 4. Phosphorus level: High. 5. Calcium level: Low in renal failure because when the phosphorus level starts going up, it inhibits calcium absorption in the GI tract, and the calcium level goes down. 5. Red blood cell count: Decrease because the kidneys aren't producing erythropoietin. If the kidneys are damaged, RBC production decreases and RBC count decreases. 6. ABGs: Metabolic acidosis in renal injury. Here the kidneys can't filter out the acids created with metabolic processes and also the buffering systems are impaired.

Nephrotic Syndrome (Causes)

1. Bacterial/Viral Infections 2. NSAIDS 3. Cancer 4. Lupus/Diabetes 5. Strep

Interventions for increased toxins and metabolic waste:

1. Bedrest 2. Diet: Low protein and high in carbs and fats

Interventions for fluid volume excess:

1. Bedrest 2. Intake and Output/ Daily weight 3. Vital signs every 2 hours/ CVP 4. Assessing lung sounds 5. Restricting fluids (by matching their output): output + 500 mLs 6. IV meds (administer their IV meds in the smallest volume that is safe)

Cardiac Tamponade (Patho)

1. Blood, fluid, or exudate leaks into the pericardial sac, compressing the heart

Cardiac Output

1. CO = HR x SV. 2. Tissue perfusion is dependent on an adequate cardiac output. 3. Cardiac output changes according to the body's needs.

Nitroglycerin (Nitrostat): Sublingual

1. Causes venous and arterial dilation. 2. This dilation will cause decreased preload and afterload. 3. Also causes dilation of the coronary arteries, which will increase blood flow to the actual heart muscle (myocardium)---then the blood will carry more oxygen. 4. Take 1 every 5 min x 3 doses. 5. It is NOT okay to swallow. 6. Keep in a dark, glass bottle; dry, cool. 7. May or may not burn or fizz (burning = normal). 8. The client will get a headache (don't call the HCP; this is NOT life-threatening). 9. Renew an average of every 6 months. Renew the spray every 2 years. 10. After nitroglycerin (Nitrostat), you expect the BP will drop because nitroglycerin causes vasodilation.

Triad for women and MI

1. Chronic Fatigue 2. Cant catch their breath 3. Indigestion

Coronary Artery Disease

1. Coronary artery disease is the most common type of cardiovascular disease. 2. Coronary artery disease is a broad term that includes chronic stable angina and acute coronary syndrome.

Renal Failure (S/S)

1. Creatinine and BUN Increase 2. Increase SG initially 3. Anemia 4. HTN AND HF 5. Anorexia, n/v 6. Itching Frost 7. Electrolyte imbalances

Acute Coronary Syndrome (S/S)

1. Crushing 2. Elephant sitting on chest 3. Pressure radiating to jaw and arm 4. Women have GI symptoms 5. SOB- #1 SIGN IN ELDERLY

Cardiac Tamponade (S/S)

1. Decreased CO 2. Increased CVP 3. Drop in BP 4. Muffled Heart sounds 5. Narrowed pulse pressure 6.

Chronic Stable Angina:

1. Decreased blood flow -> Ischemia 2. Occurrence: Predictable 3. Pain occurs because of: Decreased O2, usually from exertion 4. Rest and Nitroglycerin: Relieves pain Patho: we have decreased blood flow, which leads to ischemia, usually caused by coronary artery disease. Pain is predictable and it is normally as a result of decreased oxygen. This is often due to some type of exertion, like we have listed: exercise, a big meal, or temperature extremes. Pain is generally relieved by rest and/or nitroglycerin.

Unstable Angina or MI:

1. Decreased blood flow -> Ischemia and Necrosis 2. Occurrence: Unexpected, Unprompted 3. Pain occurs because of: Poor blood flow through the myocardial vessels (blood clot formation, impending MI) 4. Rest and Nitroglycerin: Normally does not relieve pain Patho: the client does NOT have to do anything to bring on this pain. It's unpredictable and it's NOT relieved by rest or nitroglycerin. The more unstable the angina, the closer they are to having an MI.

Right Sided Heart Failure (S/S)

1. Distended neck veins 2. Edema 3. Enlarged organs 4. Weight Gain 5. Ascites

Nephrotic Syndrome (Treatment)

1. Diuretics 2. ACE Inhibitors 3. Prednisone 4. Lipid lowering drugs 5. Increase Protein 6. Anticoag therapy 7. Dialysis

Pulmonary Edema (Medications)

1. Diuretics 2. Nitroglycerin 3. Morphine 4. Nesiritide

Interventions to decrease preload:

1. Elevate the head of the bead 2. Dangle the elgs 3. Low salt diet 4. Diuretics 5. Vasodilators

Calcium Channel Blockers (for prevention of angina):

1. Examples: nifedipine (Procardia XL), verapamil (Calan), amlodipine (Norvasc), diltiazem (Cardizem). 2. These decrease the BP. 3. Calcium channel blockers cause vasodilation of the arterial system. 4. They dilate coronary arteries (getting more oxygen to the heart muscle). 5. Two benefits of calcium channel blockers are they decrease afterload and increase oxygen to the heart muscle.

Beta Blockers (for prevention of angina):

1. Examples: propranolol (Inderal), metoprolol (Lopressor/Toprol XL), atenolol (Tenormin), carvedilol (Coreg). 2. Beta blockers decrease the BP, P, and myocardial contractility (take the client's HR and BP before administration). 3. This decreases the workload of the heart. 4. Beta blockers block the beta cells... these are the receptor sites for catecholamines - the epi and norepi. 5. If we just decreased the contractility, the CO decreases. 6. We have decreased the workload on the heart. 7. This is a good thing to a certain point, because when we decrease the work of the heart, the need for oxygen is decreased, and that decreases angina. But, we could decrease the client's cardiac output (HR and BP) too much with these drugs.

Pulmonary Edema (Patho)

1. Fluid is backing up into the lungs 2. Occurs at night

Glomerulonephritis (Treatment)

1. Get rid of strep 2. Rest and Activity 3. I &O and Daily Weights 4. Monitor BP 5. Increase cards 6. Dialysis

Factors that affect cardiac output:

1. Heart rate and certain arrhythmias (bradycardia and tachycardia can decrease cardiac output). 2. Blood volume (Less volume = decreased cardiac output. More volume = increased cardiac output. EX: from surgery/burns). 3. Decreased contractility (MI, medication, cardiac muscle disease; things that affect the contractility of the heart).

Interventions for hyperkalemia:

1. IV glucose and insulin 2. Polystyrene sulfonate or Kayexalate 3. Loop diuretics (to promote the loss of potassium) 4. A low potassium diet 5. Calcium gluconate at the bedside (for dysrhythmias)

Pathophysiology of decreased cardiac output:

1. If your CO is decreased, will you perfuse properly? No. 2. Brain: LOC will go down. 3. Heart: Client reports chest pain. 4. Lungs: Lungs sound wet. Shortness of breath. 5. Skin: cold and clammy. 6. Kidneys: UO goes down. 7. Peripheral pulses: weak; less volume = less pressure. Arrhythmias are no big deal UNTIL they affect your cardiac output.

Glomerulonephritis (Patho)

1. Inflammatory reaction in the glomerulus 2. Decreased filtering because antibodies get lodged 3. Main cause is streptococcal

Pathophysiology of Chronic Stable Angina:

1. Intermittent decreased blood flow to the myocardium leads to ischemia. This ischemia can lead to temporary pain/pressure in the chest. 2. Low oxygen usually due to exertion brings this pain on. 3. Rest and/or nitroglycerin SL relieves the pain.

1. What does an increase in afterload do to the workload of the heart? 2. Is this a good thing or a bad thing?

1. It increases the workload of the heart. 2. It is a bad thing because we NEVER want to increase the workload on the heart.

Troponin

1. Most sensitive indicator of an MI 2. Elevated within 3-4 hours and remains elevated for up to 3 weeks

Vasodilators:

1. Nitroglycerin 2. ACE Inhibitors 3. ARBs

Treatment for MI When they get to the ED

1. Oxygen 2. Aspirin 3. Chewable Nitro 4. Morphine

Chronic Arterial Insufficiency

1. Pain: Intermittent claudication (progresses to pain at rest) 2. Pulses: Decreased or may be absent. 3. Color: Pale when elevated, red with lowering of leg. 4. Temperature: Cool. 5. Edema: Absent or mild. 6. Skin Changes: Thin, shiny, loss of hair over foot/toes, nail thickening. 7. Ulceration: If present, will involve toes or areas of trauma on feet (painful). 8. Gangrene: May develop. 9. Compression: Not used.

Chronic Venous Insufficiency

1. Pain: None to aching pain, depending on dependency of area. 2. Pulses: Normal (may be difficult to palpate due to edema). 3. Color: Normal (may see petechiae or brown pigmentation with chronic condition). 4. Temperature: Normal. 5. Edema: Present. 6. Skin Changes: Brown pigmentation around ankles, possible thickening of skin, scarring may develop. 7. Ulceration: If present, will be on sides of ankles. 8. Gangrene: Does not develop. 9. Compression: Used.

When cardiac output is decreased:

1. Perfusion - down. 2. LOC - down. 3. Skin - pale, clammy, and cold. 4. Lungs - they may have shortness of breath. 5. Urinary output - it will be down. 6. Peripheral pulses - they will be weak. 7. Blood pressure - down. 8. Pulse - it will go up to compensate for decreased cardiac output. 9. Chest pain - yes; because decreased cardiac output causes ischemia. Ischemia is due to decreased oxygen to the heart muscle and this causes pain.

Cardiac Tamponade (Treatment)

1. Pericardiocentesis to remove blood around the heart 2. Surgery

Renal Failure 3 Types

1. Pre-renal - Blood isn't getting to the kidneys due to decreased CO 2. Intra-renal - Damage has occurred in the kidney due to glomerulonephritis, nephrotic syndrome, dyes, drugs, malignant hypertension 3. Post-renal - Urine can't get out of the kidney due to enlarged prostate, kidney stone, ureter obstruction, tumor, or edematus stoma

Medication Effects on Cardiac Output:

1. Preload: Vasodilate or diurese to reduce (decrease) preload. Example: Diuretics (furosemide), Nitrates (nitroglycerin). 2. Afterload: Vasodilate to reduce (decrease) afterload. Example: ACE Inhibitors (enalapril, fosinopril, captopril), ARBS (losartan, irbesartan). 3. Improve Contractility: Inotropes (dopamine, dobutamine, milrinone). 4. Rate Control: Beta Blockers (propranolol, metoprolol, atenolol, carvedilol), Calcium Channel Blocker (diltiazem, verapamil, amlodipine), Digoxin. 5. Rhythm Control: Antiarrhythmics (Amiodarone).

Nephrotic Syndrome (S/S)

1. Proteinuria 2. Hypoalbuminemia 3. Edema 4. Hyperlipidemia

Left Sided Heart Failure (S/S)

1. Pulmonary Congestion 3. Dyspnea and cough 4. Blood tinged frothy sputum 5. Restlessness and Tachycardia 6. S-3 7. Orthopnea

Three Arrhythmias that are always a big deal:

1. Pulseless V-Tach 2. V-Fib 3. Asystole

Client Education/Teaching for Chronic Stable Angina:

1. Rest frequently. 2. Avoid overeating,. 3. Avoid excess caffeine or any drugs that increase HR. 4. Wait 2 hours after eating to exercise. 5. Dress warmly in cold weather (any temperature extreme can precipitate an attack)---we are trying to decrease the workload of the heart. 6. Take nitroglycerin prophylactically (example: walking up the stairs). 7. Smoking cessation. 8. Lose weight (decrease calories in their diet). 9. Avoid isometric exercise (make muscle squeeze and tense up, which increases the workload of the heart---NO weight-lifting). 10. Reduce stress (example: guided imagery/music therapy).

1. Pulmonary hypertension can also lead to __________. 2. What is another name for this type of right-sided heart failure? 3. Blood is backing up into the venous system, so what symptoms will we see?

1. Right-sided heart failure. 2. Cor pulmonale. 3. Those that have to do with the body---distended neck veins, edema, enlarged organs, weight gain. Weight gain from all the fluid that is being retained.

Glomerulonephritis (S/S)

1. Sore throat 2. Malaise, Headache 3. Inc. BUN and Creatinine 4. Sediment/Protein/Blood in the urine 5. Flank pain 6. Increased BP 7. Facial Edema 8. Decreased UO

Diuretic Phase of Renal Failure

1. Sudden 2. UO Increases 3. FVD 4. Decreased K+

Pulmonary Edema (S/S)

1. Sudden Onset 2. Breathless 3. Restless/Anxious 4. Severe hypoxia 5. Productive Cough (Pink froth sputum)

Oliguric Phase of Renal Failure

1. UO- 100 to 400ml/24 hours 2. FVE 3. Increased K +

Elevate- Dangle-

1. Veins 2. Arteries

Critical Thinking Scenario: The nurse is caring for a client following abdominal surgery. The client is NPO with a NGT to low intermittent suction. The nurse notes copious amounts of dark brown fluid in the drainage container, BP is 88/58, pulse is 110, and urinary output was 26 mL/hr for the last hour.

1. What are we worried about? We are worried about shock. Shock can lead to renal injury or failure; so I need to report this scenario to the primary healthcare provider immediately to save all the vital organs. 2. What told you to worry about shock in this scenario? Post abdominal surgery, NPO, NGT to suction with copious amount of drainage, BP of 88/58, pulse 110, urinary output of 26 mL/hr. 3. Are the kidneys in this client perfusing adequately? NO. 4. How do I know? A BP of 88/58 is just too low, and the urine output of 26 mL/hr proves it. The minimum urine output per hour for an adult is 30 mL/hr and you really should be worried before the urine output gets down to 30 mL/hr. 5. If this decreased perfusion lasts very long, then what could happen? Renal failure. 6. What type of renal failure could they develop? Would it be pre, intra, or post renal failure? It's pre-renal failure because the problem prevents blood from getting to the kidneys.

Critical Thinking Scenario: The nurse is caring for a diabetic client 24 hours post abdominal CT scan with contrast. 24-hour Intake and Output: Shift: 7-3 Intake: 420 Output: 240 Shift: 3-11 Intake: 360 Output: 120 Shift: 11-7 Intake: 180 Output: 30 Total: Intake: 960 Output: 390

A CT scan with contrast and the output has been decreasing over the last 24 hours. 1. Can contrast dye cause renal complications? Yes, it's called "contrast induced nephropathy" and it's more common if the client has diabetes, heart disease, or renal disease. Always check renal function before a study that uses contrast dye. These dyes are excreted by the kidneys and can cause renal damage. 2. Is this pre, intra, or post renal failure? Intra-renal failure. 3. What two diseases can lead to intra-renal failure? Glomerulonephritis and nephrotic syndrome.

What would the nurse include when preparing a teaching plan for a client scheduled to begin hemodialysis three days per week? Select all that apply. 1. A weight will be taken before and after dialysis. 2. Consuming too much fluid can lead to heart damage. 3. Limit protein intake to 3 ounces per day while on dialysis. 4. Notify the primary care provider if a vibration is not felt over the access site. 5. Wash the access site with soap and warm water each day and before dialysis.

ANS: 1, 2, 4, 5. Rationale: 1. True; during dialysis, the weight will go down as fluid is removed. A liter of fluid weighs 2.2 pounds or one kilogram. You can determine how much fluid is being removed by weighing the client before, during, and after the dialysis therapy. 2. True; teach them to be compliant with fluid restrictions because we know that excess fluid increases the blood pressure and increases the workload of the heart. 3. False; renal dieticians encourage most people on hemodialysis to eat high-quality protein because it produces less waste for removal during dialysis. High-quality protein comes from meat, poultry, fish, and eggs. The client is allowed 8 to 10 ounces of high protein foods daily. Even though peanut butter, nuts, seeds, dried beans, peas, and lentils have protein, these foods are generally not recommended because they are high in both potassium and phosphorous. 4. True; we are teaching the client to feel the thrill because this means that there is good blood flow through the AV shunt or vascular access . 5. True; to prevent infection at the access site. Don't teach them to wash multiple times per day because that will dry out the skin and it could cause dry and cracked areas. What else could you teach the client about the hemodialysis access? You may want to teach them: no BP in the arm, no shots or needle sticks in the arm, no constrictive clothing or anything on the arm, don't even carry a purse on that arm.

Which tasks can the nurse assign to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collect a urine specimen from a urinary catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the urinary catheter of a client post transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.

ANS: 2, 4, 6. These are all tasks that can be performed by the UAP. Look at those verbs. The UAP can obtain a BP, document or record I&O, and perform the hygiene tasks like perineal care. Rationale: 1. Incorrect; because telling is teaching and the UAP cannot teach. 2. Correct; 3. Incorrect; because this requires sterile procedure, which is not within the scope of the UAP. 4. Correct; 5. Incorrect; because this requires sterile procedure, which is not within the scope of the UAP. 6. Correct;

A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment finding should be reported to the primary healthcare provider? 1. Hemoglobin level of 10 g/dl (1.6 mmol/L). 2. Blood pressure of 120/84. 3. Potassium of 3.7 mEq/L (3.7 mmol/L). 4. Thrill and bruit absent on palpation.

ANS: 4. Thrill and bruit absent on palpation. Rationale: Erythropoietin is generally well tolerated. The purpose of the medication is to increase red blood cell production. Now, if the client has an increase in RBCs, would that increase the coagulability of the blood? Yes, and one of the first places that it may be noted is the vascular access. 1. Incorrect; because the purpose of this drug is to increase hemoglobin levels. A level of 10 g/dL would be considered favorable, even though still a little low. The client would need to continue the medication since anemia still exists. If the hemoglobin is above 12 g/dL, the level should be reported, at this point the client does not need the med any longer. 2. Incorrect; you need to know that an elevated blood pressure is one of the more common and major side effects. If elevated, it should be reported, but this blood pressure is within normal limits. 3. Incorrect; this is a normal potassium level, so there is no problem here. 4. Correct; if you do not palpate a thrill or heart a bruit, the client's access does not have a good blood flow and could be clotted off. Clients taking this drug are also at risk for myocardial infarctions and risk of blood clots.

The nurse is caring for a client who has just arrived at the ER with suspected acute myocardial infarction. Which medications should the nurse expect to administer? Select all that apply. A. Oxygen B. Heparin C. Morphine D. Sublingual nitroglycerin E. Furosemide

ANS: A, C, D A. Oxygen, C. Morphine, D. Sublingual nitroglycerin. Rationale: suspected MI-- what do these hints tell us that we need to focus on? Emergency medical management of an MI. The medications that should be administered to a client with a suspected MI are oxygen, morphine, and nitroglycerin. Heparin and furosemide may be given later if the client has a confirmed MI or if they go into heart failure, but these are not safe to give in the emergency treatment. A. Oxygen is a drug. Oxygen is also a vital treatment for someone that has hypoxia and ischemia to the heart muscle. If someone is having an MI, they have ischemia and necrosis, so oxygen would definitely help that. If their oxygen saturation is less than 90%, give them oxygen. B. Heparin is an anticoagulant, but is this a part of the initial emergency management for a suspected MI? No, it's not. It can be used in the treatment of a known heart attack, but remember, the question said "suspected." C. Morphine; when someone is suspected of having an MI, morphine causes arterial vasodilation and helps relieve the pain. Morphine would be a great medication for emergency treatment of a suspected MI if the pain is not relieved by nitroglycerin. Just be sure to monitor their respiratory rate after administration. D. Nitroglycerin; Always be sure you assess how many doses of nitroglycerin they have already had taken before getting to the emergency department. The rule is one tablet or spray every 5 minutes up to 3 doses. With the client that has taken nitroglycerin, we need to assess for orthostatic hypotension (remember, it's a safety thing)---check their blood pressure because they may feel dizzy from the vasodilation effect of the nitroglycerin. Always remember safety. E. Furosemide; it's a diuretic. Furosemide is not part of the emergency treatment and there's nothing in the question that indicates a fluid problem. Also, you must know the category or classification of your medications to use your good judgement and pick the correct answer for the pertinent hints in the question.

A child is diagnosed with glomerulonephritis after presenting with malaise, weight gain, edema, and headache. The primary healthcare provider prescribes antibiotics and strict bedrest. Which explanations are best to give the client and caregivers regarding the strict bedrest prescription? Select all that apply. A. Promotes diuresis B. Prevents injury C. Promotes rest D. Stimulates RBC production E. Decrease protein breakdown

ANS: A, C, E. Rationale: The same child now has a confirmed diagnosis of glomerulonephritis and the family wants to know why the child must be on bed rest. Bed rest promotes diuresis in two ways---in the release of ANP and with the decreased production of ADH. A. Correct; because this client has edema and bedrest will promote diuresis. B. Incorrect; prevents injury---they can't hurt themselves if they're in bed, but that's not the rationale for the prescription. C. Correct; the client's lethargic and they need to conserve energy. D. Incorrect; stimulates red blood cell production---it's not related to bedrest. E. Correct; strict bed rest will also decrease metabolism. Now, if i can decrease metabolism, then the body will not need to break down proteins for energy. That's a good thing here, because the kidneys are not able to filter the BUN (blood urea nitrogen) properly in glomerulonephritis. ANS C. & E. are rationales for the strict bedrest prescription. The true answers are A., C., and E.; these options will help to decrease the severity of the child's symptoms of glomerulonephritis and these are the rationales for the primary healthcare provider prescribing strict bedrest.

A client reports crushing chest pain 3 hours prior to arrival in the ER. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? Select all that apply. A. Initiate cardiac monitoring. B. Insert urinary catheter. C. Position client in recumbent position. D. Restrict physical activity. E. Administer dopamine at 5 mcg/kg/min. F. Prepare for central line placement.

ANS: A. B., D., E., F. A. Initiate cardiac monitoring. B. Insert urinary catheter. D. Restrict physical activity. E. Administer dopamine at 5 mcg/kg/min. F. Prepare for central line placement. Rationale: this client is exhibiting signs of cardiogenic shock, which is a complication of myocardial infarction---an MI. Hypotension, along with a weak, thready pulse, and cool, clammy skin, indicates inadequate organ perfusion. Since the client has confusion, what organ is not being perfused? The brain. What needs to be done for this client in shock? A. True; the client is in shock and can start having dysrhythmias, so cardiac monitoring is appropriate. B. True; shock will lead to decreased perfusion of vital organs such as the kidneys. Poor perfusion to the kidneys for 20 minutes can lead to renal failure, so we need to be able to monitor their urine output and make sure that it is above 30 mL/hr. C. False; when a client is in cardiogenic shock, we do not lie them down! This would increase the workload on the heart. You want to decrease the workload of the heart by elevating the head of the bed. D. True; the more the client moves, the more oxygen is required. The client's heart is not working well due to an MI, so limit activity to decrease oxygen demands. E. True; dopamine is the drug of choice to improve cardiac contractility in clients with hypotension. The effects of dopamine on the myocardium result in increased heart rate, increased cardiac contractility, which is a good thing when the blood pressure is low, because this helps to increase cardiac output. F. True; placement of a central line will provide vascular access for multiple infusions and allow for monitoring of central venous pressures. In regard to the low blood pressure in the question----if the blood pressure is dropping, what am I worried about? Shock, but what happens to the cardiac output when in shock (regardless of what kind of shock it is)? Decreased cardiac output. Patho: damaged or dead heart muscle---dead tissue doesn't pump very well, so the cardiac output is going to do down.

A nurse notes that a client with acute renal injury has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client? Select all that apply. A. Encourage use of cotton gloves during sleep. B. Apply emollients to the skin. C. Increase protein rich foods in the diet. D. Cut fingernails short. E. Provide mouth care prior to meals.

ANS: A., B., D., E. Rationale: A. True; the patho behind the uremic frost that is associated with renal disease---this frost causes pruritus, which is another word for itching skin, so you want to have them use gloves because if they do scratch, gloves will reduce the risk of dermal injury. B. True; emollients and lotion will aid dry, itchy skin. C. Incorrect; it is wrong because protein is the problem---that's where urea comes from. So we want to decrease protein, not increase it. D. True; cutting nails short will decrease risk of skin breakdown when scratching. E. True; we can figure out that uremic halitosis must be from a build-up of urea in the body. It produces a metallic taste in the mouth. Mouth care prior to meals will help in eliminating this taste.

Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distention, an S3 heart sound, a BP of 100/60 mmHg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? A. Notify the primary healthcare provider. B. Stop the IV fluid infusion. C. Elevate the head of the bead. D. Observe for cardiac arrhythmias.

ANS: C. Elevate the head of the bead. Rationale: what is the biggest concern in this question? Orthopnea and dyspnea---these are the killer problems, so we must focus on them first. A. Incorrect; calling the primary healthcare provider is fine if you do it AFTER you do something to try to fix the breathing problem. B. Incorrect; stopping the IV fluid can be done after helping the client to breathe. C. Correct; elevate the head of the bed first. The client is reporting inability to breathe. Orthopnea means the client needs to sit up to breathe better. With any client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing signs and symptoms of heart failure---we've got to help them to breathe first, then we can do all of the other things later. D. Incorrect; after an MI we know we are going to observe the client for cardiac arrhythmias. However, this does not fix the breathing problem.

A child is being admitted to the hospital with an elevated BUN and Creatinine, swelling around the eyes and a headache. Which information should the nurse report immediately to the primary health care provider? A. Play football and basketball. B. Takes acetaminophen three times a day for headache. C. Sores on face and hands a few weeks ago. D. Salmonella outbreak recently in the school cafeteria.

ANS: C. Sores on face and hands a few weeks ago. Rationale: You know the client has an increase in BUN and creatinine, has experienced a headache, plus facial edema. You should be thinking that the kidneys are in trouble. With the kidney in mind, which of the options is very important? A. Incorrect; you may think these symptoms are a result of a sports injury, which is possible, but the facial edema would not be a symptom and that would make this option wrong. B. Incorrect; I may worry about the liver, but I have no liver symptoms right now. C. Correct; this child may have had impetigo caused by strep and now has glomerulonephritis. Remember, a bacterial infection can cause the filtering units of the kidneys or the glomeruli to become inflamed, and this results in a decreased ability of the kidneys to filter the urine. The disorder may develop 1-2 weeks after an untreated throat infection or 3-4 weeks after a skin infection. As the nurse, you must report to the primary care provider your finding of the history of sores on the face, because this could mean impetigo or another strep infection. Strep could be causing glomerulonephritis, and treatment needs to be started to prevent further kidney damage. D. Incorrect; salmonella would present with GI symptoms, not the kidney.

A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction (MI)? A. I became dizzy when I stood up. B. I was nauseated and began vomiting. C. The pain started in my chest and stopped after I sat down. D. The pain was not relieved after taking 3 nitroglycerin tablets.

ANS: C. The pain started in my chest and stopped after I sat down. Rationale: A. False; dizziness with standing indicates orthostatic hypotension which is not definitive for angina or MI. B. False; vomiting is a symptom of MI, not angina, and is a bad sign related to the acute pain from the MI. This type of pain stimulates the vagus nerve, which causes the heart rate, blood pressure, and cardiac output to decrease. This is never good with a heart client. C. True; chest pain brought on by exercise, which stopped with rest, is the hallmark sign of angina. If it were an MI, the pain would continue, even with rest or position changes. D. False; this is the picture of MI, not angina, and when this happens, we need to worry. Would the type of chest pain described in the answer of this scenario be chronic stable angina or unstable angina?

A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? A. Draw blood for arterial blood gases. B. Place compression hose on legs. C. Insert indwelling catheter for hourly urinary output. D. Administer furosemide 20 mg intravenous push (IVP).

ANS: D. Administer furosemide 20 mg intravenous push (IVP). Rationale: Our client did have a heart attack and now we doing our assessment. We find that they have developed crackles bilaterally in the lungs. You must pick the ONE best option that will fix the problem. A. False; you will need to draw these to evaluate the oxygenation status, but this option will not be your priority over removing the fluid from the lungs. B. False; compression hose will help prevent stagnation of blood in the lower extremities to prevent deep vein thrombosis. This is great nursing care, but not priority when fluid is developing in the lungs. C. False; the indwelling catheter can be inserted after administration of the diuretic. You'll be glad you have that indwelling catheter, but it's not the prescription that is going to help with the fluid overload problem. D. True; the client's developing pulmonary edema or heart failure and needs to be diuresed to remove excess fluid. The question stem tells you that you have prescriptions for these four options, so what are you going to do first? All prescriptions are possible, but furosemide will fix the problem.

Acute Kidney Injury AKA:

Acute Renal Failure

What happens to afterload in a client with hypertension?

Afterload increases. High blood pressure causes more resistance to pump against, so afterload increases in a client with hypertension.

Who would have problems with hemodialysis?

Anyone who has a heart condition. During dialysis, they will have BP fluctuations while the fluid is being removed. Remember, in between dialysis exchanges, fluid builds up and they have fluid volume excess, which is hard on their heart.

Who would have a hard time with peritoneal dialysis?

Clients who have had multiple abdominal surgeries because of scarring of the peritoneal membrane, clients with colostomies, and clients with back problems would have trouble as well.

If a client has fluid volume deficit, is preload increased or decreased?

Decreased preload because there's less fluid returning to the heart.

In fluid volume deficit, is cardiac output increased or decreased?

Decreased. Fluid volume deficit equals decreased cardiac output.

Testing Strategy:

Do everything you can to decrease the workload on the heart.

CCPD (Continuous cycle peritoneal dialysis)

Done at night while they sleep, constant sweet taste, may get a hernia

Acetylsalicylic Acid (Aspirin):

Dose is determined by the primary healthcare provider (81 mg - 325 mg)---"low-dose baby aspirin."

CPK-MB

Elevated within 3-6 hours and peaks in 12-24 hours

How do vasodilators affect preload and afterload?

For preload, if you decrease venous return, you will decrease preload. Nitrates like nitroglycerin cause vasodilation and venous pooling, which decreases cardiac preload and the symptoms of congestion. If afterload is based on aortic and peripheral resistance, then vasodilation is needed to decrease afterload---vasodilators are needed.

Anytime you suspect a kidney stone, what do you do?

Get a urine specimen and check for RBCS

Compare and Contrast: Glomerulonephritis versus Nephrotic Syndrome

Glomerulonephritis: 1. Streptococcal infections are the most common cause of glomerulonephritis. 2. Protein loss. 3. Blood in urine (hematuria). 4. Facial edema. BOTH: 1. Both diseases are a result of an inflammatory response within the glomerulus. 2. Toxins and malaise. 3. Increase in blood pressure. 4. Decreased urine output. 5. Can progress to acute renal injury and even to renal failure. Nephrotic Syndrome: 1. Multiple causes or idiopathic. 2. Massive protein loss. 3. Anasarca; is not just edema. It's total body edema and it's the hallmark sign of nephrotic syndrome. Anasarca and facial edema are not equal. The edema is extensive in nephrotic syndrome because the protein loss is so extensive---it's massive. 4. Hyperlipidemia. 5. Clotting problems.

Systolic Heart Failure

Heart can't contract and eject

If the increased preload is not treated, what develops?

Heart failure.

CRRT

Icu, never more than 80 mL of blood out of the body at a time

Critical Thinking Scenario: The nurse is caring for a client who has been admitted for a transurethral resection of the prostate (TURP) due to benign prostatic hyperplasia (BPH). The client tells the nurse, "I am ready to get this surgery done. I have the urge to pee but very little is coming out."

If very little urine is being excreted, you better put this client on an hourly output. 1. If the prostate has obstructed the flow of urine will do what? Back up into the kidneys. Could that injure the kidney? It can cause acute renal injury or failure. What type? Post-renal failure. Any problem that blocks urine from leaving the kidney can cause post-renal failure. We want to watch this client closely pre-op and post-op to be sure that urine flow is not obstructed.

Peritoneal Dialysis needs

Increased fiber and protein

Myoglobin

Increases within 1 hours and peaks in 12 hours

If my heart can't handle an increased preload, where does the volume back up?

Into the body.

What happens to cardiac output if preload, afterload, or stroke volume change?

It could decrease.

Nephrotic Syndrome (Patho)

Losing a lot of protein because big holes form b/c of inflammation in the glomerulus Without protein, vascular space can't hold fluid so it goes into tissues (edema) Body senses FVD, so aldosterone is produced Retention of Na and Water occurs, but no protein to hold onto it so it goes into the tissues again (more edema) Resulting in anasarca

Cardiac Catheterization

Pre-procedure: 1. Ask if they are allergic to shellfish or iodine. Iodine based dye is used during the procedure. 2. We want to check kidney function because the dye is excreted through the kidneys (could cause renal failure). Many primary healthcare providers prescribe acetylcysteine (Mucomyst) pre-procedure, especially if the client has kidney problems. Acetylcysteine helps to protect the kidneys. 3. Hot shot. 4. Palpitations are normal. Post-procedure: 1. Monitor VS. 2. Watch puncture site for bleeding and hematoma formation. 3. Watch for bleeding 4. Assess extremity distal to puncture site for the 5 Ps (pulselessness, pallor, pain, paresthesia, paralysis)---ex: skin temperature, capillary refill. 5. Bed rest, flat, extremity straight for 4-6 hours (dependent on medications used). 6. Major complication post cath is hemorrhage (bleeding). -> Report pain ASAP. 7. If the client is on metformin (Glucophage) hold this medication for 48 hours post procedure. We are worried about the kidneys.

Vasodilators can be an effective treatment for clients with cardiac problems that are related to _____ or _____.

Preload or afterload.

With any kidney disease or injury, the goal is to:

Prevent the disease from becoming severe and leading to chronic renal failure or end-stage renal disease (ESRD). This is why early treatment and follow-up are important in kidney diseases.

What type of symptoms am I going to have with left-sided heart failure?

Pulmonary symptoms---If the blood is backing up into the lungs, the patient will have things like shortness of breath, wet lung sounds or crackles.

Testing Strategy:

Rule: never leave an unstable client.

Algorithm for NTG:

Take one NTG SL, after 5 minutes if chest pain/ discomfort is unimproved or worsened, activate emergency response.

Stroke Volume

The amount of blood pumped out of the ventricles with each beat.

Preload

The amount of blood returning to the right side of the heart and the muscle stretch that the volume causes. ANP is released when we have this stretch.

When the blood backs up into the lungs, which side of the heart is failing?

The left or left-sided heart failure.

A client with pulmonary edema experiences backflow from which chamber of the heart?

The left ventricle.

If my afterload is increased, where will the blood back up?

The lungs.

Afterload

The pressure in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out. This pressure is referred to as resistance. With HTN there's even more resistance for the left ventricle to pump against. That's why HTN can eventually lead to HF and pulmonary edema, because high afterload decreases cardiac output and decreases forward flow. Plus, it wears your heart out.

Which side of the heart is failing?

The right side.

If a client has splenomegaly secondary to heart failure, which ventricle is causing the backflow?

The right ventricle

Normal blood flow through the heart:

The two major veins that bring blood to the right side of the heart are the superior and inferior vena cava. (This blood is deoxygenated) -> The blood enters the right atrium. -> Then, the blood goes to the lungs where it is oxygenated. -> Next, through the pulmonary veins (they carry oxygenated blood) -> It then goes to the left atrium -> to the left ventricle (the big bad pump). -> It is then pumped into the aorta -> And finally, this oxygenated blood is delivered throughout the body through the arterial system where it eventually ties back into the venous system.

Diastolic Heart Failure

Ventricles can't relax and fill

End-stage renal disease

When a client has sustained enough renal damage to require renal replacement therapy on a permanent basis, the client has moved from acute kidney injury to chronic kidney disease or end-stage renal disease. The most common renal replacement therapy is hemodialysis.

Is blood flow altered with left-sided heart failure? Would cardiac output be altered? Are we worried about perfusion to vital organs?

Yes.

Thrombolytics should be given

within 6-8 hours of onset of myocardial pain