Exam 3 PathoBio UU online course

Associated pressures: Edema

Edema occurs when there is a decrease in plasma oncotic pressure, an increase in hydrostatic pressure (pushing). Maybe osmotic pressure (pulling).

Renal Obstruction & consequences

-Hydroureter -Hydronephrosis -Hypertrophy -Infection -HTN (renin-angiotensin-aldosterone activation) Long-standing distention of the renal pelvis and ureter can also inhibit the rhythmic muscular contractions that normally move urine down the ureter from the kidney to the bladder (peristalsis).

Which dermatologic problem most often accompanies chronic kidney disease (CKD)?

Dry, itchy skin is a common consequence of CKD. Petechiae, purpura, hirsutism, psoriasis, alopecia, and fungal rashes are not noted to accompany or result from CKD.

Accumulation of nitrogenous wastes such as urea in the circulatory system is an early sigh of chronic kidney disease (CKD). The nurse knows that normal levels of urea in blood are approximately:

20 mg/dL (7.14 mmol/L); Normal levels of blood urea nitrogen are approximately 20 mg/dL or less. The level increases as CKD worsens and can go as high as 800 mg/dL (285.60 mmol/L).

pulmonary embolism

A blood clot that breaks off from a large vein and travels to the blood vessels of the lung, causing obstruction of blood flow. Mechanism: Although pulmonary embolism can arise from anywhere in the body, most commonly it arises from the calf veins. The venous thrombi predominately originate in venous valve pockets (inset) and at other sites of presumed venous stasis.

chronic bronchitis

A clinical diagnosis of chronic bronchitis requires the history of a chronic productive cough for at least 3 consecutive months over 2 consecutive years. This is not noted to be a strong genetic component of the disease, and childhood RSV is not a risk factor. Immunization status is normally linked to the development of bronchitis

Basic mechanisms and examples of bowel disorders

Inflammation, Malabsorption, and Obstruction

An increased anterior-posterior chest diameter

An increased anterior-posterior chest diameter is referred to as a barrel chest. Although some in the medical community may use the term "pink puffer" to help remember the typical presentation of emphysema, this term and "blue bloater" related to chronic bronchitis are inappropriate for a medical record. A pneumothorax does not affect the anterior-posterior chest diameter.

A client has been diagnosed with chronic kidney disease (CKD). Which drug category is usually administered to treat coexisting conditions that manifest early in CKD?

Antihypertensive medications; Hypertension is a common result of CKD, and the mechanisms that produce hypertension in CKD include increased vascular volume, elevation of peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin-angiotensin-aldosterone system. NSAIDs, opioids, and antiarrhythmics are not as frequently indicated for the treatment of CKD.

A client with chronic kidney disease (CKD) has developed asterixis. The nurse knows that asterixis is:

Asterixis, which is involuntary dorsiflexion of hands and feet, can develop as CKD worsens. Burning sensation in feet, unsteady gait and demyelination of nerves can also accompany CKD, but are not part of asterixis.

The nurse is caring for a client who has had acute blood loss from ruptured esophageal varices. What does the nurse recognize is an early sign of prerenal failure?

Baseline urine output of 50 mL/hr that is now 10 mL/hr; The kidney normally responds to a decrease in the glomerular filtration rate with a decrease in urine output. Thus, an early sign of prerenal failure is a sharp decrease in urine output.

Acute-onset bronchial asthma causes wheezing and breathlessness as a result of which of the following?

Bronchial asthma represents a reversible form of obstructive airway disease caused by narrowing of airways due to bronchospasms, inflammation, and increased airway secretions; this inflammatory process produces recurrent episodes of airway obstruction, characterized by wheezing, breathlessness, chest tightness, and cough. Vascular flow through the lungs is unaffected by airway inflammation and bronchospasms. Hyperinflated alveoli are characteristic of the emphysema type of obstructive pulmonary disease. Compression atelectasis is associated with high external pressure that blocks lung expansion.

The nurse caring for four male clients recognizes which client is at highest risk for developing postrenal kidney failure?

Client with prostatic hyperplasia; The most common cause of postrenal kidney failure is prostatic hyperplasia. Postrenal failure results from conditions that obstruct urine outflow. The obstruction can occur in the ureter, bladder, or urethra. Intratubular obstruction and acute pyelonephritis are intrarenal causes of kidney failure, and severe hypovolemia is a prerenal cause.

pulmonary vessels are exposed to hypoxemia

Continued exposure of the pulmonary vessels to hypoxemia is a common cause of pulmonary hypertension. Unlike blood vessels in the systemic circulation, most of which dilate in response to hypoxemia and hypercapnia, the pulmonary vessels constrict.

The nurse is instructing a client with advanced kidney disease (AKD) about a dietary regimen. Which restriction should the nurse be sure to include in the treatment plan to decrease the progress of renal impairment in people with AKD?

Dietary protein; Restriction of dietary proteins may decrease the progress of renal impairment in people with advanced renal disease. Proteins are broken down to form nitrogenous wastes, and reducing the amount of protein in the diet lowers the blood urea nitrogen and reduces symptoms.

A client is beginning to recover from acute tubular necrosis. During which phase of acute kidney injury will the nurse assess an increase in urine output?

Diuretic phase; The onset phase lasts hours/days and is the time from the onset of the precipitating event until tubular injury occurs. The oliguric phase is characterized by a marked decrease in glomerular filtration rate, causing sudden retention of endogenous metabolites, such as urea, potassium, sulfate, and creatinine. The diuretic phase occurs when the kidneys try to heal and one will see an increase/excessive output (diuresis) of dilute urine. The recovery phase is the period during which tubular edema resolves and renal function improves. There is normalization of fluid and electrolyte balance.

Glomerular filtration rate (GFR) is the best indicator of renal function. The nurse knows that GFR can vary with which factors?

Ethnicity, Age, Gender, Body size; GFR, the best indicator of overall renal function, varies with age, gender, body size, and ethnicity. Equations are available for calculating GFR based on serum creatinine and these variables. Diet, if it includes sufficient fluid intake to maintain hydration, should not affect GFR.

an asthmatic attack in a child with a diagnosis of extrinsic, or atopic, asthma?

Extrinsic or atopic asthma is typically initiated by a type I hypersensitivity reaction induced by exposure to an extrinsic antigen or allergen such as pet dander. Intrinsic or nonatopic asthma triggers include respiratory tract infections, exercise, hyperventilation, cold air, drugs and chemicals, hormonal changes and emotional upsets, airborne pollutants, and gastroesophageal reflux.

The health care provider is reviewing laboratory results of a client. Select the diagnostic test that is considered the best measurement of overall kidney function.

GFR is the best overall measure of kidney function. GFR is usually estimated using the serum creatinine concentration. Creatinine, a by-product of muscle metabolism, is produced at a fairly constant rate, is freely filtered in the glomerulus, and is not reabsorbed in the renal tubules. Essentially all of the creatinine filtered by the kidneys is lost in the urine; therefore, serum creatinine is an indirect measure of GFR. Proteinuria serves as a key adjunctive tool for measuring nephron injury and repair. Urine normally contains small amounts of protein. Blood tests for BUN and creatinine provide information regarding the ability to remove nitrogenous wastes from the blood.

A nurse is assessing a client for early manifestations of chronic kidney disease (CKD). Which would the nurse expect the client to display?

Hypertension is commonly an early manifestation of CKD. The mechanisms that cause the hypertension are multifactorial: they include increased vascular volume, increased peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin-angiotensin-aldosterone system. Impotence occurs in as many as 56% of males on dialysis. Terry nails are a dark band just behind the leading edge of a fingernail followed by a white band that occurs in the late stages. Asterixis, a sign of hepatic encephalopathy, is due to the inability of the liver to metabolize ammonia to urea.

Basic mechanisms and examples of liver disease & manifestations

If signs and symptoms of liver disease do occur, they may include: Skin and eyes that appear yellowish (jaundice) Abdominal pain, and swelling. Swelling in the legs and ankles There are diseases such as Hepatitis viral infections A-E and Cirrhosis caused by alcohol. The 3 main cause of the liver disease is obesity (fatty liver disease), an undiagnosed hepatitis infection, and alcohol misuse.

The GFR is considered to be the best measure of renal function. What is used to estimate the GFR?

In clinical practice, GFR is usually estimated using the serum creatinine concentration.

Intrisinc or Intrarenal AKI

In intrinsic acute renal failure, there is damage to the renal parenchyma. Caused by acute tubular necrosis (ATN). Mechanism:

Vitamin D metabolism is deranged in clients with chronic kidney disease (CKD). The nurse recognizes that which statement regarding vitamin D is correct?

Inactive vitamin D is converted to active calcitriol in the kidneys. Calcitriol enhances gastrointestinal absorption of calcium, and suppresses release of PTH. Elevated levels of PTH are characteristic of CKD as blood levels of phosphate rise and levels of calcium fall.

increased capillary hydrostatic pressure

Increased capillary hydrostatic pressure (as occurs when venous pressures become elevated by gravitational forces, volume expanded states, in heart failure or with venous obstruction). Hydrostatic edema refers to accumulation of excess interstitial fluid which results from elevated capillary hydrostatic pressure

Pyelonephritis

Inflammation of the renal pelvis and kidney; caused by bacterial infection. Infectious inflammatory response ascending from lower urinary tract. Abscess formation and tubular necrosis.

In hemodialysis, access to the vascular system is most commonly through:

Internal arteriovenous fistula; Access to the vascular system is accomplished through an external arteriovenous shunt (i.e., tubing implanted into an artery and a vein) or, more commonly, through an internal arteriovenous fistula (i.e., anastomosis of a vein to an artery, usually in the forearm).

Prolonged immobility is implicated in the development of which disorder?

Lack of mobility can result in secondary atelectasis (through incomplete lung expansion) and pulmonary embolism (from deep vein thrombosis). This is not the case with the other listed disorders of ventilation and gas exchange.

lymphatic obstruction.

Lymphatic obstruction is a blockage of the lymph vessels that drain fluid from tissues throughout the body and allow immune cells to travel where they are needed. Lymphatic obstruction may cause lymphedema, which means swelling due to a blockage of the lymph passages.

asthma

Mechanism: The pathophysiology of asthma is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness. Mechanism during exacerbation: edema, inflammation, mucus hypersecretion and the formation of inspissated mucus plugs, as well as structural changes including hypertrophy and hyperplasia of the airway smooth muscle. Types: Cough Variant, Allergic, and Non-Allergic

asthma, emphysema, pulmonary embolism, hypertension, ARDS

Perfusion disorders & mechanisms

A client with stage 5 chronic kidney disease (CKD) is presenting with fever and chest pain, especially when taking a deep breath. The nurse detects a pericardial friction rub on auscultation. Which condition does the nurse suspect is common with this stage of kidney disease?

Pericarditis; Pericarditis occurs in many people with stage 5 CKD due to the uremia and prolonged dialysis. The manifestations of uremic pericarditis resemble those of viral pericarditis with all its potential complications, including cardiac tamponade. The presenting signs include mild to severe chest pain with respiratory accentuation and a pericardial friction rub. Fever is variable in the absence of infection and is more common in dialysis than uremic pericarditis.

The nurse will monitor which clients at risk for the development of chronic kidney disease (CKD)?

Permanent renal damage can result from systemic lupus erythematosus, polycystic kidney disease, glomerulonephritis, or diabetes. Hypertension also is a frequent cause for CKD. Hyperlipidemia does not cause CKD but may develop in clients with CKD.

unilateral chest pain

Pleuritis is usually unilateral and tends to be localized to the lower and lateral part of the chest; pain worsens with chest movements, such as deep breathing and coughing that accentuate pressure changes in the pleural cavity and increase the movement of the inflamed or injured pleural surfaces. Musculoskeletal pain usually is bilateral and may occur as the result of frequent, forceful coughing. The pain associated with irritation of the bronchi usually is substernal and dull. Myocardial pain usually is located in the substernal area and is not affected by respiratory movements.

An 86-year-old client is being treated for dehydration and hyponatremia after curtailing fluid intake to prevent urinary incontinence. Given these findings, the nurse recognizes that this client is likely in what phase of acute kidney injury?

Prerenal failure occurs when vascular volume and renal perfusion are decreased, for example by dehydration. Postrenal failure is the result of obstruction of urine outflow. Intrarenal (intrinsic) failure occurs when nephrons are destroyed.

A client diagnosed with chronic kidney disease (CKD) is experiencing nausea and vomiting. Which intervention would be most appropriate for the nurse to provide?

Restrict intake of dietary protein; Early morning nausea is common in CKD. Nausea and vomiting often improve with the restriction of dietary protein and after initiation of dialysis and disappears after kidney transplant. The other actions will not improve the symptoms.

Sarcoidosis

Sarcoidosis treatment is directed at interrupting the inflammatory process with corticosteroid medications. Sarcoidosis is overgrowth of granulomas and does not have a fungal or allergy component.

An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure. The nurse should be assessing this client for which early sign of prerenal injury

Sharp decrease in urine output; Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output. Post-renal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.

acute renal failure (ARF)

Sudden inability of the kidneys to excrete wastes, resulting from hemorrhage, trauma, burns, toxic injury to the kidney, pyelonephritis or glomerulonephritis, or lower urinary tract obstruction. Characterized by oliguria and azotemia. Types: PreRenal, Intrinsic, PostRenal Edema and hypertension, Hyperkalemia, Metabolic acidosis

decrease in the client's respiratory effort

The client cannot maintain his O2 saturation above 70%: When alveolar ventilation is inadequate to maintain PO2 or PCO2 levels because of respiratory or neurologic failure, mechanical ventilation may be lifesaving. Usually a nasotracheal, orotracheal, or tracheotomy tube is inserted into the trachea to provide the client with the airway needed for mechanical ventilation.

an amniotic emboli

The embolism may consist of amniotic fluid that has entered the maternal circulation during childbirth. Persons with moderate-sized emboli often present with breathlessness accompanied by pleuritic pain, apprehension, slight fever, and cough productive of blood-streaked sputum. Tachycardia often occurs to compensate for decreased oxygenation, and the breathing pattern is rapid and shallow. Intercostal traction is usually associated with atelectasis; pitting edema is a sign of right-sided heart failure; trachea shift is a classic sign of a tension pneumothorax.

Prerenal AKI

The most common cause of ARF. Caused by impaired renal blood flow. GFR declines because of the decrease in filtration pressure

A client with chronic kidney disease (CKD) will be managed with peritoneal dialysis. Which description of this type of dialysis is most accurate?

Treatment involves the introduction into the peritoneum of a sterile dialyzing solution, which is drained after a specified time. In peritoneal dialysis, a sterile dialyzing solution is instilled into the peritoneum through a catheter over approximately 10 minutes. The solution remains ("dwells") in the peritoneal cavity for a determined time interval, then drains into a sterile bag. Shunts, fistulas, and artificial dialyzers are associated with hemodialysis, which is usually performed three times weekly. The frequency of peritoneal dialysis varies, but is normally performed more often than hemodialysis and can be done at home.

enhanced hydraulic permeability of capillary walls

Where capillary permeability is increased locally, either by damage to the vessel wall or by the action of histamine, a local swelling known as a weal is produced. If the hydrostatic pressure is increased, as in muscle tissue during exercise, the rate of formation of tissue fluid will be increased.

decreased plasma oncotic pressure

Where plasma proteins are reduced, e.g. from being lost in the urine (proteinuria), there will be a reduction in oncotic pressure and an increase in filtration across the capillary, resulting in excess fluid buildup in the tissues (edema). Reduced oncotic pressure, typically due to hypoalbuminemia, occurs in several diseases such as renal disease where the loss of albumin occurs across the glomerulus (nephrotic syndrome).

Crohn's disease

a chronic autoimmune disorder that can occur anywhere in the digestive tract; however, it is most often found in the ileum and in the colon Mechanism: produce inflammation of the bowel; lack confirming evidence of a proven causative agent; have a pattern of familial occurrence; and can be accompanied by systemic manifestations. The pathogenesis of Crohn disease involves a failure of immune regulation, genetic predisposition, and an environmental trigger, especially microbial flora.

Emphysema

a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. Mechanism: Emphysema is one of the most preventable respiratory illnesses because it is so strongly linked to smoking. Air pollutants, an alpha-1 antitrypsin deficiency, and respiratory infections can also play a role, but smoking is considered the number one cause. Types: COPD and Chronic Bronchitis

The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents:

a loss of over half the client's normal kidney function; In clinical practice, GFR is usually estimated using the serum creatinine concentration. A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. The GFR is not diagnostic for concentrated urine or the need to drink more water.

Postrenal AKI

due to obstruction of urine flow - can occur anywhere post kidney (ureter, bladder, urethra)

Pulmonary hypertension

elevated pulmonary pressure resulting from an increase in pulmonary vascular resistance to blood flow through small arteries and arterioles. Mechanism: Increased pulmonary vascular resistance is the main pathogenic mechanism in pulmonary arterial hypertension (PAH). This is typically due to vasoconstriction, remodeling, and thrombosis of the small pulmonary arteries and arterioles

4 contributing mechanisms to Edema

increased capillary hydrostatic pressure, decreased plasma oncotic pressure, enhanced hydraulic permeability of capillary walls, and lymphatic obstruction.

Ventilation

movement of air in and out of the lungs

chronic renal failure (CRF)

progressive condition in which the kidneys cannot filter certain waste products; also called chronic kidney failure Stages: Diminished renal reserve (GFR ~50%), Renal insufficiency (GFR ~20-50 %), Renal failure (GFR < 20-25%), End-Stage Renal Disease (GFR <5%)

ARDS (acute respiratory distress syndrome)

respiratory insufficiency marked by progressive hypoxia Mechanism: acute onset tachypnea, hypoxemia, diffuse pulmonary infiltrates, and loss of lung compliance. Is believed to occur when a pulmonary or extrapulmonary insult causes the release of inflammatory mediators, promoting neutrophil accumulation in the microcirculation of the lung Phases: exudative, proliferative, and fibrotic

Glomerular disorders

result from damage to the glomerular capsular membrane of the renal corpuscles Mechanisms: autoimmune with antibodies that clogg up glomerulus and

Respiratory Diffusion

the movement of gases down their concentration gradients across the alveolar and capillary membranes