ATI Elimination/ Urinary
A nurse is caring for a client who has chronic renal failure. Which of the following should the nurse remind the client to increase in her diet?
Calcium The client should supplement calcium in to her diet because the kidneys are unable to activate calcium through the gastrointestinal track.
Cholesterol (total)
Desirable: A cholesterol below 200 mg/dL High risk: A cholesterol ↑ or equal to 240 mg/dL
A nurse is collecting a 24hr creatinine clearance. During the collection, the client accidentally discards a specimen. Which of the following is an appropriate nursing action?
Discard the previous collection and start the collection again. Rationale: All urine voided in a 24hr must be collected, or the test results will not be accurate.
A nurse is caring for a client receiving peritoneal dialysis. Which of the following is a complication of this procedure?
Infection Rationale: The danger of peritonitis requires a sterile techniques, closed sterile instillation and drainage systems, and frequent cultures of peritoneal drainage.
A nurse is reinforcing teachings to a client scheduled for a vasectomy about the procedure. Which of the following client statements indicates an understanding of the procedure?
"I need to have a two follow-up negative sperm count." Rationale: Contraceptive measures need to be used until after sperm analysis are negative. Sperm can remain viable for up to 6month in the vas deferens.
A nurse is caring for a client with recurrent kidney stones. The provider order several diagnostic studies, including intravenous pyelogram (IVP), urine culture and sensitivity, and strain all urine. The nurse needs to inquire further if the client states which of the following?
"I never eat shellfish because they give me hives." Rationale: Getting hives after eating shellfish is a likely indication of an allergy. The contrast medium used for IVP dye is typically an iodine or shellfish derivative. A client with sensitivity to iodine or shellfish may have an anaphylactic reaction after the contrast material is injected.
A nurse is caring for a client with a history of cystitis. Which of the following statements indicates a need for further education?
"I prefer to take baths instead of showers." Rationale: Women who have frequent uti's are encouraged to take showers instead of baths. A tub bath is more likely to cause irritation and contamination of the urethra; therefor, leading to frequent uti's.
A nurse is caring for a client with chronic renal failure. Which of the following client statements indicates an understanding of the dietary needs for lifestyle management of this disease?
"I will limit my fluid intake." Rationale: The client who has chronic renal failure needs to avoid hypovolemia, or fluid overload , by following the fluid restriction each daily. Protein restriction will also be necessary to avoid elevating the serum BUN levels.
A nurse is caring for a client who is to undergo a cystoscopy. When reinforcing teaching to the client on post-procedure expectations, which of the following should the nurse state?
"Pink tinged urine and burning while urinating can be expected." Rationale: Cystoscopy is a direct look inside the clients bladder through a small camera that is inserted through the urethra. It is a common test used to look for causes to bleeding in the urine and other bladder problems. Following the procedure, pink tinged urine and burning on urination is to be expected.
A nurse is caring for a client who is receiving hemodialisis via the left arteriovenous fistula for management of chronic renal disease. Which of the following teaching points should the nurse reinforce?
Avoid tight clothing around the access site. Rationale: Tight clothing may decrease the blood flow and cause clotting.
WBC
5,000-10,000
Glycosylated Hemoglobin (HgbA1C)
A non-diabetic person will have an A1c result ↓ than 5.7% Diabetes: A1c level is 6.5% or higher Increased risk of developing diabetes in the future: A1c of 5.7% to 6.4%
43. A client hospitalized with urolithiasis has a sudden significant decrease in urine output. The nurse would immediately: a) call the physician b) replace the foley catheter with a new one c) tell the client to drink increased fluids d) obtain a urine specific gravity
A- A sudden significant decrease in urine output, to either oliguria or anuria, represents obstruction of the urinary tract, usually at the bladder neck or urethra. This represents a medical emergency, requiring prompt treatment to preserve kidney function. In this instance, the nurse would call the physician to report the findings immediately. There are no data in the question to indicate that a Foley catheter is present. Obtaining a urine specific gravity will not relieve the obstruction. Telling the client to increase fluid intake is incorrect. Additionally, if an obstruction is present, increasing fluids can cause hydronephrosis.
The nurse is evaluating the effects of care for the client with nephrotic syndrome. The nurse determines that the client showed the least amount of improvement if which of the following information was obtained serially over 2 days of care? a) serum albumin 1.9g/dL, up to 2.0g/dL b) initial weight 208 pounds, down to 203 pounds c) blood pressure 160/90mm Hg, down to 130/78mm Hg d) daily intake and output of 2100 ml intake and 1900 ml output 2000 ml intake and 2900 ml output
A- The goal of therapy in nephrotic syndrome is to heal the leaking glomerular membrane. This would then control edema by stopping the loss of protein in the urine. Fluid balance and albumin levels are monitored to determine the effectiveness of therapy. Option B represents a loss of fluid that slightly exceeds 2 L and that represents a significant improvement. Option C shows improvement, because both systolic and diastolic blood pressures are lower. Option D represents a total fluid loss of 700 mL over the 2 days, which is also helpful. The least amount of improvement is in the serum albumin level, because the normal albumin level is 3.5 to 5.0 g/dL.
A nurse is caring for a client who has begun using peritoneal dialysis. The nurse determines that which manifestation indicates the onset of peritonitis? a) oral temperature of 100F b) history of gastrointestinal (GI) upset 1 week ago c) clear dialysate output d) presence of crystals in dialysate output
A- Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. The complaint of GI upset is too vague to be correct. Peritonitis would cause cloudy dialysate but would not cause crystals to appear in the dialysate.
A client who has never been hospitalized before is having trouble initiating the stream of urine. Knowing that there is no pathological reason for this difficulty, the nurse avoids which of the following because it is the least helpful method of assisting the client? a) running tap water in the sink b) assisting the client to a commode behind a closed curtain c) instructing the client to pour warm water over the perineum d) closing the bathroom door and instructing the client to pull the call bell when done
B- A lack of privacy is a key issue that may inhibit the ability of the client to void in the absence of known pathology. Using a commode behind a curtain may inhibit voiding in some people. The use of a bathroom is preferable, and this may be supplemented with the use of running water or pouring water over the perineum, as needed.
39. A nurse is caring for a client who is receiving immunosuppressant therapy including corticosteroids following a renal transplant. The nurse would plan to carefully monitor which laboratory result for this client? a) serum albumin b) blood glucose c) magnesium d) potassium
B- Corticosteroid therapy can result in glucose intolerance, leading to elevated blood glucose levels. The nurse monitors these levels to detect this side effect of therapy. With successful transplant, the client's serum electrolyte levels should be better regulated, although corticosteroids could also cause sodium retention.
A female client with a history of chronic urinary tract infection complains of burning and urinary frequency. To determine whether the current problem is of renal (kidney) origin, the nurse would assess whether the client has pain or discomfort in the: a) suprapubic area b) right or left costovertebral angle c) urinary meatus d) labium
B- Pain or discomfort from a problem that originates in the kidney is felt at the costovertebral angle on the affected side. Ureteral pain is felt in the ipsilateral labium in the female client, or the ipsilateral scrotum in the male client. Bladder infection is often accompanied by suprapubic pain and pain or burning at the urinary meatus when voiding.
LAXATIVES: Bulk - Forming Agents
Bran Calcium Polycabophil (FiberCon) Methylecellulose (Citrucel) Psyllium Hydrophilic Mucilloid (Metamucil, EfferSyllium) Action: Contains indigestible bulk fiber that softens the stool mass by drawing water into the Use: Laxative - can be used on a regular basis Route: PO in the morning or with meals. Mix in a cool glass of liquid, such a water, milk, or fruit juice Side Effects: Impaction if not given with adequate amount of liquid Nursing Implications: -Avoid giving at HS to prevent impaction -Do not give if the client has an impaction or bowel obstruction -Mix in adequate amounts of fluid to prevent the bulk laxative from obstructing the GI tract. -Encourage a minimum of 6 - 8 glasses of water daily
A client with nephrotic syndrome asks the nurse, "Why should I even bother trying to control my diet and the edema? It doesn't really matter what I do if I can never get rid of this kidney problem, anyway!" The nurse selects which of the following as the most appropriate nursing diagnosis for this client? a) anxiety b) powerlessness c) ineffective coping d) disturbed body image
B- Powerlessness is present when the client believes that personal actions will not affect an outcome in any significant way. Because nephrotic syndrome is progressive, the client may feel that personal actions may not affect the disease process. Anxiety is diagnosed when the client has a feeling of unease with a vague or undefined source. Ineffective coping occurs when the client has impaired adaptive abilities or behaviors with regard to meeting expected demands or roles. Disturbed body image occurs when there is an alteration in the way that the client perceives his or her body image.
Loop Diuretics
Block reabsorption of sodium, chloride and water into the loop of Henle, these are most effective. Side effects: dehydration, hypokalemia, ototoxicity do not take w/aminoglycosides Types: Furosemide (Lasix), bmetanide (Bumex), ethacrynic asid (Edecrin), torsemide (Demadex)
38. A clinic nurse is reviewing the laboratory results of an adult client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which of the following is noted on the laboratory results? a) 35 mg/dL b) 29 mg/dL c) 15 mg/dL d) 3 mg/dL
C-The normal BUN ranges from 5 to 25 mg/dL. Options A and B reflect elevated values, which may indicate renal abnormalities or dehydration. Option D reflects a lower than normal value, which may not be clinically significant.
A client is being discharged to home while recovering from acute renal failure (ARF). The client indicates an understanding of the therapeutic dietary regimen if the client states the need to eat foods that are lower in: a) fats b) vitamins c) potassium d) carbohydrates
C - Most of the excretion of potassium and the control of potassium balance are normal functions of the kidneys. In the client with renal failure, potassium intake must be restricted as much as possible (30 to 50 mEq/day). The primary mechanism of potassium removal during ARF is dialysis. Options A, B, and D are not normally restricted in the client with ARF unless a secondary health problem warrants the need to do so.
42. A nurse is providing discharge instructions to a client after a hydrocelectomy. Which statement by the client would indicate a need for further instructions? a) I should apply ice packs to the scrotum b) I should keep the scrotum elevated until the swelling has gone away c) the sutures will be removed by the doctor in a few days d) I need to avoid sexual intercourse at this time
C- A hydrocele is an abnormal collection of fluid within the layers of the tunica vaginalis that surrounds the testis. It may be unilateral or bilateral and can occur in an infant or adult. Hydrocelectomy is the excision of the fluid filled sac in the tunica vaginalis. The client needs to be instructed that the sutures used during the hydrocelectomy are absorbable. The other options are correct.
The nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). The nurse determines that which of the following is the priority for the postprocedure care of this client? a) maintaining the client on bedrest b) ambulating the client in the hallway c) encouraging the increased intake of oral fluids d) encouraging the client to try to void frequently
C- After IVP, the client should take in increased fluids to aid in the clearance of the dye used for the procedure. It is unnecessary to void frequently after the procedure. The client is usually allowed activity as tolerated, without any specific activity guidelines.
48. A client who is newly diagnosed with chronic renal failure is scheduled for hemodialysis this morning and asks he nurse why the daily dose of enalapril (Vasotec) has not been given. The nurse tells the client that this medication will be given: a) just before going to hemodialysis b) during the hemodialysis c) when dialysis is completed d) at bedtime
C- Antihypertensive medications such as enalapril are given to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis, and prevents the medication from being removed from the bloodstream during dialysis. There is no rationale to wait until bedtime to resume the medication. Erratic dosing could lead to ineffective blood pressure control.
ANTIDIARRHEAL: Opium and Opium Derivatives
Camphorated Tincture of Opium Tincture of Opium Difenoxin (Motofen) Diphenoxylate (Lomotil, Logen) Loperamide Hydrochloride (Imodium) Action: Inhibits peristalsis which allows for more water absorption Use: Diarrhea Route: PO Side Effects: CNS depression with the opium derivatives, may be habit forming, abdominal distension if used excessively, constipation, nausea Nursing Implications: -Report abdominal distension -Assess for contraindications and drug interactions -Observe for increased effects of other CNS depressants
A nurse is caring for a client who is suspected of having a UTI. The provider prescribes a urine specimen. Which of the following findings should confirm to the nurse that an upper UTI involving the kidney is present?
Casts Rationale: Casts are protein structures that are precipitated in the renal tubules. Presence of the these in the urine indicates a pathologic condition of the kidney.
A nurse is caring for a client receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input, the abdomen is distended, and the client is reporting pain. Which of the following is an appropriate nursing action?
Change the client's position. Rationale: Dialysate solution is infused through the catheter in the abdominal wall into the peritoneal space. If the client appears to be retaining the dialysate solution, the client should change positions to facilitate the drainage of the solution from the peritoneal cavity.
Laxatives:
Chemicals that act to promote the evacuation of the bowel sub classified based on mechanism of action
Combination Drugs
Common to combine two or more drugs when treating HTN and fluid retention disorders. May give 2 separate meds or a single tablet combination Example: Aldactazide: hydrochlorothiazide and sironolactone
A client with chronic renal failure has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen of the client gains no more than how much weight between hemodialysis treatments? a) 2 to 4kg b) 5 to 6kg c) 0.5 to 1kg d) 1 to 1.5kg
D- A limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
A nurse is caring for a client at risk for acute renal tubular necrosis following a crush injury to the leg. The nurse implements which measure to minimize this particular risk for the client? a) use of sheepskin and bed cradle b) frequent position changes in bed c) administration of antibiotics in a timely fashion d) careful monitoring of intravenous fluids to ensure sufficient intake
D- After a crush injury, myoglobin released from damaged muscle cells circulates in the bloodstream and can clog renal tubules. It is important to maintain an increased fluid intake to "flush" the kidneys and minimize this occurrence. The other options may be part of the management of this client but do not specifically relate to this potential complication.
Stimulant Laxatives:
Irritant to intestine - promote peristalsis and evacuation within 6-10 hours (orally) or within 60-90 min (rectally) Ex-lax, Peri-colace, Dulcolax (also softens stool)
Alpha Adrenergic Blockers
Terazosin (Hytrin), Doxazosin (Cardura) Tamsulosin (Flomax) (Does not decrease BP) Action: Relaxes the smooth muscle in the prostate, urethra, and bladder neck which reduces the urethral obstruction. Use: Improves urinary flow and symptoms of BPH Side Effects: Orthostatic hypotension, H/A, dizziness
Fecal Softeners:
Wetting agents - draw water into stool causing it to soften Do not stimulate peristalsis May take up to 72 hours Depends on pt's hydration & GI transit time Docusate sodium (Colace) Docusate calcium (Dulcolax)
Trichomoniasis
Diagnosis: wet-mount slide, UA, or pap test Treatment: metronidazole (Flagyl), except those pregnant in the first trimester, then clotrimazole Risk to neonate occurs at birth by direct contact with protozoan
Renal stone
Terminology: Calculus: Stone Lithiasis: Formation of stone Nephrolithiasis: Stone formation within the kidney Urolithiasis: Development of stones within the urinary tract.
Renal Failure Kidneys unable to remove waste products from blood
Acute or chronic, most common cause of acute renal failure is ischemia (poor profusion) of the kidneys, and nephrotoxins (agents that damage kidney tissue). Azotemia: toxic condition in which nitrogenous compounds in the blood are not removed due to renal failure Fluid, electrolyte, acid-base imbalances - can be the result of azotemia
Inflammatory Bowel Disease
A group of chronic disorders in the small and large intestine that cause inflammation or ulcerations of GI tissue.
A nurse is working on a renal unit in a local hospital. The nurse interprets that which client with renal failure is best suited for peritoneal dialysis as a treatment option? a) a client with severe congestive heart failure b) a client with a history of ruptured diverticuli c) a client with a history of herniated lumbar disk d) a client with a history of three previous abdominal
A- Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease, which would be worsened by the rapid shifts in fluid, electrolytes, urea, and glucose that occur with hemodialysis. Contraindications to peritoneal dialysis include diseases of the abdomen, such as ruptured diverticuli or malignancies, extensive abdominal surgeries, history of peritonitis, obesity, and history of back problems, which could be aggravated by the fluid weight of the dialysate. Severe disease of the vascular system also may be a contraindication.
Hemorrhoids
Anorectal Lesions Anal Fissure Anorectal Abscess Anorectal Fistula Pilonidal Disease Anorectal Lesions Teaching: Diet, Fluids, Prevent constipation Post operative care
The nurse has given instructions about site care to a hemodialysis client who had an implantation of arteriovenous (AV) fistula in the right arm. The nurse determines that the client needs further instructions if the client states the need to: a) sleep on the right side b) avoid carrying heavy objects with the right arm c) perform range-of-motion exercises routinely on the right arm d) report an increased temperature, redness, or drainage at the site
A- Routine instructions to the client with an AV fistula, graft, or shunt include reporting signs and symptoms of infection, performing routine range-of-motion exercises of the affected extremity, avoiding sleeping with the body weight on the extremity with the access site, and avoiding carrying heavy objects or compressing the extremity that has the access site.
A client with chronic renal failure has a protein restriction in the diet. The nurse should include in a teaching plan to avoid which of the following sources of incomplete protein in the diet? a) nuts b) eggs c) milk d) fish
A- The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are complete proteins with the highest biological value. Foods such as meat, fish, milk, and eggs are complete proteins, which are optimal for the client with chronic renal failure.
47. A nurse is preparing to teach a client who is newly diagnosed with chronic renal failure about the disease and its management. The client has a diminished ability to learn because of uremia and anxiety. The nurse makes it a priority to include which of the following when conducting teaching sessions with this client? a) family members b) charts and diagrams c) research articles d) lengthy printed materials
A- The client with chronic renal failure may have several barriers to learning, including anxiety and the effects of uremia, such as short attention span and memory deficits. Uremic effects usually improve once hemodialysis has begun. The presence of family is helpful because the family needs to understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. Information should also be simple, direct, and at the educational level of the client to be most effective. Charts and diagrams may be helpful but are not the priority. Research articles will not be helpful.
50. A client who is newly diagnosed with chronic renal failure is scheduled to begin hemodialysis. The nurse interprets which of the following neurological or psychological findings exhibited by the client to be atypical? a) euphoria b) labile emotions c) withdrawal d) depression
A- The client with chronic renal failure often experiences a variety of psychosocial changes. These are related to uremia as well as the stress experienced by the client with a chronic, life-threatening disease. These clients 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.
Imaging Studies
Abdominal X-ray: KUB, Intravenous pyelography: IVP Retrograde pyelography, CT or MRI Renal scan, Renal arteriogram, Bladder scan, Ultrasound, Cystoscopy
Colostomy care
Assess stoma; protect skin, selecting the pouch, & assisting pt to adapt psychologically Stoma - should be pink (reddish-pink) Dusky blue - ischemia Brown-black - necrosis Mild to moderate swelling 1st 2-3 weeks Skin barrier should be applied - stomahesive, Hollister skin barriers Wash skin with warm water and dry thoroughly before barrier applied Colostomy in ascending & transverse colon - semi liquid stools Colostomy in sigmoid or descending colon - semi formed or formed stools and can sometimes be regulated by irrigation method
Irritant or Stimulant Laxatives
Bisacodyl (Doculax, Bisco-Lax, Theralax) Phenolphthalein (Feen-A-Mint, Phenolax) Cascara Sagrada Senna (Senna Laxative, Fletcher's Castoria) Castor Oil Action: Stimulates intestinal motility and secretions which causes watery stools. Use: Bowel Prep, Constipation, Nausea Route: PO on an empty stomach Side Effects: Phenolphtalein may turn urine pink or red, abdominal cramping and pain, Nursing Implications: -Drug can be habit forming, do not use for more than 1 week at time -Do not crush enteric coated Bisacodyl tablets
40. A client who has been diagnosed with chronic renal failure has been told that hemodialysis will be required. The client becomes angry and withdrawn, and states, "I'll never be the same now." The nurse formulates which of the following nursing diagnoses for this client? a) disturbed thought processes b) disturbed body image c) anxiety d) noncompliance
B- The client with any renal disorder, such as renal failure, may become angry and depressed because of the permanence of the alteration. Because of the physical change and the change in lifestyle that may be required to manage a severe renal condition, the client may experience Disturbed body image. Options A, C, and D are unrelated to the client's statement.
An adult with renal insufficiency has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 AM to 3:00 PM? a) 400 b) 600 c) 800 d) 1000
B- When a client is on a fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
44. A nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse should take which action? a) stop the peritoneal dialysis b) obtain a culture and sensitivity of the drainage c) institute hemodialysis temporarily d) add antibiotics to the next several dialysis bags
B- When the drainage becomes cloudy, peritonitis is suspected. A culture and sensitivity is obtained, and broad-spectrum antibiotics are added to the dialysis solution, pending culture and sensitivity results. The dialysis solution may also be heparinized to prevent catheter occlusion. Some clients must switch to hemodialysis if peritonitis is severe or recurring, but the nurse does not make this decision. The peritoneal dialysis is not stopped
Abnormal components of urine
Bacteria - present with infection Blood - hematuria: smoky-colored or brown. With frank bleeding - bright red Casts - dish-shaped mucus particles. Normal to find limited number in urine that is otherwise normal in color Protein - Small amts sometimes present in normal urine, amts large enough to be measured is abnormal Pus - pyuria - indicates infectious process Stones - calculi - formed from various kinds of salts that precipitate Glucose - none
Gonorrhea
Diagnosis: cervical, rectal or throat culture Treatment: penicillin, tetracycline, Rocephin, Cipro and others
Thiazide Diuretics
Block the reabsorption of sodium and chloride and increases the excretion of K+ and water in the early distal tubule Most frequently prescribed Side effects similar to Loop but less Types: Hydrochlorothiazide (Microzide), bendroflumethiazide and nadolol (Corzide), metolazone (Zarozolyn), chlorthalidone (Hygroton), indapamide (Lozol), methyclothiazide (Enduron)
Potassium-Sparing Diuretics
Blocks the reabsorption of sodium and reduce the secretion of potassium in the late distal tubule and collecting ducts Less side effects Weak diuretic effect Spironolactone (Aldactone), amiloride (Midamor), eperenone (Inspra), triamterene (Dyrenium)
A nurse is caring for a client who has under-gone a non-related living donor kidney transplant. On the 5th postoperative day, the nurse notes that the client has gained 1kg of body weight since the previous day. The nurse suspects rejection. Which of the following would also be seen in a client experiencing rejection?
Blood Pressure of 160/90mm/Hg Rationale: If the client is having kidney rejection, that will be accompanied by kidney failure. Consequently, due to the kidneys role in fluid and blood pressure regulation, the client experiencing rejection will typically be hypertensive.
ABG's
Blood gas measurements are used to evaluate a person's lung function and acid/base balance. BG Element Normal Value Range pH 7.4 7.35 to 7.45 Pa02 90mmHg 80 to 100 mmHg Sa02 93 to 100% PaC02 40mmHg 35 to 45 mmHg HC03 24mEq/L 22 to 26mEq/L Metabolic acidosis is characterized by a lower pH and decreased HCO3-, causing the blood to be too acidic for proper metabolic/kidney function. Causes include diabetes, shock, and renal failure
Renal Function
Blood urea nitrogen: BUN Serum creatinine level and creatinine clearance test (24 hour UA) (Creatinine levels are the best indicator of renal problems!) Estimated glomerular filtration rate
Bowel Obstruction
Bowel Obstruction Pathophysiology Mechanical or functional, Paralytic ileus , Clinical Manifestations Complications: Hypovolemic shock, Strangulated colon Management Diagnostic tests, Gastric decompression, Fluids and electrolytes, Surgery
At the beginning of the work shift. the nurse is checking a client who has returned from the post-anesthesia care unit following transurethral resection of the prostate (TURP). The client has bladder irrigation running via a three-way Foley catheter. The nurse should notify the physician if which color if urine is noted in the urinary drainage bag? a) pale pink b) dark pink c) bright red d) tea-colored
C- Bright red bleeding should be reported, because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP, but may be noted in the client with renal failure or other renal disorders.
49. A nurse is teaching a client with chronic renal failure about fluid restriction. The nurse tells the client which of the following dessert items from the dietary menu represents the best choice? a) ice cream b) sherbet c) angel food cake d) jell-O
C- Dietary fluid includes anything that is liquid at room temperature. This includes items such as ice cream, sherbet, and Jell-O. With clients on a fluid restricted diet, it is helpful to avoid "hidden" fluids to whatever extent is possible. This allows the client more fluid for drinking, which can help alleviate thirst.
46.A nurse is admitting a client with chronic renal failure to the nursing unit. The nurse anticipates that the client will exhibit which frequent cardiovascular sign associated with chronic renal failure? a) pulse 110 beats per minute b) pulse 56 beats per minute c) blood pressure 168/94 mm Hg d) blood pressure 96/64 mm Hg
C- Hypertension is commonly associated with chronic renal failure. This results from a number of mechanisms, including volume overload, renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and the absence of prostaglandins. Hypertension may also be the cause of the renal failure. It is an important item to assess because hypertension can lead to heart failure in the chronic renal failure client as a result of increased cardiac workload in conjunction with fluid overload. Options A, B, and D are not specifically associated with chronic renal failure.
A client undergoing long-term peritoneal dialysis is experiencing a problem with reduced outflow from the dialysis catheter. The nurse assessing the client would inquire whether the client has had a recent problem with: a) vomiting b) diarrhea c) constipation d) flatulence
C- Reduced outflow may be caused by catheter position and adherence to the omentum, infection, or constipation. Constipation may contribute to reduced outflow in part because peristalsis seems to aid in drainage. For this reason, bisacodyl suppositories are sometimes used prophylactically, even without a history of constipation. The other options are unrelated to impaired catheter drainage.
41. A nurse is caring for a client who has been diagnosed as having a kidney mass. The client asks the nurse the reason for renal biopsy when other tests such as computed tomography (CT) scan and ultrasound are available. In formulating a response, the nurse incorporates the knowledge that renal biopsy : a) helps differentiate between a solid mass and a fluid-filled cyst b) provides an outline of the renal vascular system c) gives specific cytological information about the lesion d) determines if the mass is growing rapidly or slowly
C- Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system. Although some types of cancer grow more quickly than others, it is not possible to determine this by biopsy.
A client has been diagnosed with urolothiasis in the right ureter. The nurse would expect the client to describe the pain (renal colic) as: a) located in the upper right epigastric area, radiating to the shoulder or back b) occurring 2 to 3 hours after meal c) intermittent in the right upper abdominal quadrant, radiating to the groin d) worsening with the ingestion of food
C- Renal colic is generally associated with acute obstruction of a ureter and resulting ureteral spasm. As the stone moves along the ureter, the pain can be excruciating, is intermittent in character, and is located in the flank and upper abdominal quadrant of the affected side. It is caused by the spasm of the ureter and anoxia of the ureter wall from the pressure of the stone. The pain follows the anterior course of the ureter down to the suprapubic area and radiates to the external genitalia (groin). Options A, B, and D describe pain characteristic of gastrointestinal problems (cholecystitis, duodenal and gastric ulcers, respectively).
The nurse provide home-care instructions to a client who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further instructions? a) I need to include prune juice in my diet b) I need to avoid strenuous activity for 4 to 6 weeks c) I can lift and push objects up to 30 pounds in weight d) I need to maintain a daily intake of 6 to 8 glasses of water
C- The client needs to be advised to avoid strenuous activity for 4 to 6 weeks and to avoid lifting items that weigh more than 20 pounds. Straining during defecation is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant. The client needs to consume a daily intake of at least 6 to 8 glasses of nonalcoholic fluids to minimize clot formation.
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). The nurse determines that the flow rate is adequate if the color of the urinary drainage is: a) dark cherry b) clear as water c) pale yellow or slightly pink d) concentrated yellow with small clots
C- The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or that has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
While reading the product literature regarding ofloxacin (Floxin), the nurse notes that the medication could cause crystalluria. The nurse decides to tell the client taking the medication to do which of the following to decrease the likelihood of this adverse effect? a) avoid beverages that contain salts, such as mineral water b) avoid carbonated soft-drink beverages c) drink at least 1500 to 2000 ml of fluid per day d) drink at least three glasses of milk per day
C- To prevent crystalluria, the client should drink at least 1500 to 2000 mL of fluid per day. Milk interferes with the absorption of the medication and should be avoided. Consumption of carbonated beverages or mineral water is not harmful.
A client has been diagnosed with acute pyelonephritis. The nurse assesses the client for which manifestation of this disorder? a) low-grade fever b) flank pain on the unaffected side c) chills and nausea d) pale, dilute urine
C- Typical manifestations of acute pyelonephritis include high fever, chills, nausea and vomiting, flank pain on the affected side with costovertebral angle tenderness, general weakness, and headache. The client often exhibits the typical signs and symptoms of cystitis, with production of urine that is foul smelling and cloudy or bloody, and with an increased urinary white blood cell count.
A client with acute renal failure has an elevated blood urea nitrogen (BUN). The client is experiencing difficulty remembering information due to uremia. The nurse avoids which of the following when communicating with this client? a) giving simple, clear directions b) including the family in discussions related to care c) giving thorough, lengthy explanations of procedures d) explaining treatments using understandable language
C- the client with acute renal failure nay have difficulty remembering information and instructions because of anxiety and the increased level of the BUN. The nurse should avoid giving lengthy explanations about procedures because this information may not be remembered by the client and could increase client anxiety.
Urinary Obstructions
Causes of obstructions: Calculi, strictures, tumors, kinked ureter, congenital anomalies, enlarged prostate; Can occur anywhere from kidney to urethra Complications: Hydronephrosis, uremia Management: Find and remove blockage!
Short Bowel Syndrome: Surgical removal of a section bowel resulting in loss of intestinal surface
Causes: - impaired absorption of nutrients Treatment -Frequent, small, high calorie, high protein feedings
Polycystic Kidney Disease: Slow and progressive hereditary disease that causes the kidneys to become enlarged with numerous fluid filled cysts in the epithelial cells of the nephrons. The kidneys may become 2-3 times their normal size. One of the most common genetic diseases 2 forms: Childhood - rare autosomal recessive disorder in which almost 100% of the nephrons are involved at birth. Progresses rapidly. Less common than the adult form. These individuals usually die in early childhood. Adult - Autosomal dominant disorder. May be latent for years and then manifests between 30 - 40 years. Cysts enlarge and destroy surrounding tissue by compression. Cysts filled with fluid - may contain pus or blood. Child has 50% chance of getting the disease if the parent has the disease.
Clinical Manifestations Flank pain, Microscopic or gross hematuria, Proteinuria, Polyuria, Nocturia, UTIs, Kidney stones, Hypertension Treatment: No specific treatment Prevent infections Nephrectomy if necessary Manage increased BP Manage end stage renal disease
Kidney Tumors- (Renal Tumors) Renal cell carcinoma most common primary tumor Risk factors: Males, Over 55, Smoking , Obesity, Renal calculi
Clinical Manifestations: Often silent with few S/S, Painless hematuria , Anemia or polycythemia, Weakness & fatigue, Weight loss, Abdominal mass Diagnosis: Lab Tests: Increased BUN, Increased Serum Creatinine Diagnostic tests: Renal ultrasound, CT scan, Kidney biopsy Treatment: Radical Nephrectomy May also need chemo and/or radiation
Cystitis Most common type of urinary tract infection Bladder mucosa inflamed and congested with blood
Clinical Manifestations: Dysuria, Frequency, urgency, Hematuria, Pyuria, Nocturia Diagnosis: UA - see WBC (pyuria - presence of WBC in urine) Definitive with gram stain or urine culture (100,000 bacteria or above = UTI) Clean catch midstream UA Treatment - Sulfa antibiotics - Bactrim - have client drink a lot of water with this medication as it can form crystals Antispasmodic - Pyridium - decrease bladder spasms, analgesic effect - stains urine reddish-orange - permanently stains clothing Recurrent infection common - follow up UA and culture to determine complete elimination of all bacteria
Pelvic Inflammatory Disease (PID)
Clinical Manifestations: high fever, vag discharge, sever lower abd pain, malaise, dysuria, nausea, dyspareunia, dysmenorrhea Complications: infertility, ectopic pregnancy due to scarring of fallopian tubes and systemic infection Keep pt on bedrest in semifowlers position to promote drainage and localize infection Diagnosis: culture, WBC, ultrasonography, laparoscopy Medications: antibiotics, analgesics, fluids
Urethritis: Inflammation of the urethra Common in males - common cause STD - usually gonorrhea. Females, urethritis is often due to irritation (tight clothes, soap, powders, intercourse). Seen in post-menopause due to tissue changes caused by decreased estrogen levels.
Clinical manifestations: Urethral swelling, dysuria, urethral discharge, burning Cause Bacterial or viral. Diagnosis: Culture urethral tissue and pyuria (WBC's in the urine) Treatment: Based on identifying & treating cause & symptomatic relief, Antibiotics if indicated
Nephrotic Syndrome Not a disease but a group of symptoms Results from damage to glomerular membranes and severe protein loss in urine Minimal change disease most common cause in children Primary kidney disorders or systemic diseases most common cause in adults
Clinical manifestations: Anorexia, Weakness, Significant proteinuria, Low serum albumin levels, High blood lipids, Edema - may be severe Complication: Thromboemboli Treatment Usually resolves without long term effects - in children. Adults usually have some long term effects. In adults, proteinuria and renal impairment can result in renal failure. Diet - low sodium diet with protein restriction Medications - diuretics and ace inhibitors to reduce the edema and protein loss glucocorticoids (prednisone) - help with remission
Normal characteristics of urine:
Color - pale yellow (straw) to amber Clarity - clear or transparent, but will become cloudy when standing Odor - aromatic Specific gravity - measures concentration: 1.005 - 1.030 pH - 4.5 - 8
Chlamydia
Diagnosis: culture of infected tissue or blood tests In men: if gonorrhea excluded but signs of inflamation present - diagnostic of Chlamydia Treatment: doxycycline, azithromycin. Need to treat partner simultaneously!
3 stages of the disease Syphilis (primary Primary syphilis: ◦ develop painless chancre on the genital, anus, mouth, etc (3-4 weeks after contact) ◦ Chancre heals within 4-6 weeks. Secondary syphilis ◦ 2 weeks to 6 months after chancre disappears. Pale, red rash (macule and papule) develops on skin, primarily palms and soles, headache, anorexia, joint pain, fever, alopecia. If untreated will progress into the latent stage. Is very infectious, even without S/S in these two stages Latent stage ◦ the organism is no longer contagious and may last for multiple years
Complications: ◦ Paralysis, blindness, mental illness, cardiovascular damage and death ◦ Fetal infection:Transmitted transplacentally ◦ Can lead to tertiary symptoms in newborn Diagnosis: ◦ VDRL, RPR: non-specific tests ◦ FTA-ABS: specific for causative agent, used to confirm VDRL and RPR tests ◦ Immunofluorescent staining or dark-field microscopy; identifies presence of causative organism in a specimen obtained from a chancre or by aspirating a lymph node Treatment: Penicillin G, IM (single dose for 1st 2 stages, increased dose if unknown duration or more than 1 year. Follow-up testing in 3&6 mo. For 1st 2 stages, 6&12 mo for late stage disease
Prolapses
Cystocele: prolapse of bladder into vagina Rectocele: prolapse of rectum into vagina Uterine prolapse: Downward displacement of uterus into vaginal canal
A nurse is caring for a hospitalized client with polycystic kidney disease who has intravenous pyelography (IVP). The nurse monitors which specific item in the postprocedure period? a) lung sounds b) groin area c) carotid pulse rate d) intake and output
D- IVP is used to visualize the kidneys, ureters, and bladder for evaluation of structure and excretory function. Contrast medium is injected intravenously (usually in a vein located in the antecubital area) to visualize the renal parenchyma, collecting system, ureter, and bladder, using multiple x-ray films. This diagnostic test detects renal masses and cysts, ureteral obstruction, retroperitoneal tumors, renal trauma, and other urinary tract abnormalities. The nurse monitors urinary output and renal function for 24 to 48 hours after the test in order to recognize a nephrotoxic response to the contrast medium. Options A, B, and C are unrelated to this procedure.
A nurse is reviewing the health care record of a client with a diagnosis of benign prostatic hyperplasia. The nurse that which sign exhibited by the client occurs late in the disorder? a) nocturia b) decreased force of urine stream c) difficulty initiating urine stream d) hematuria
D- Nocturia, decreased force, and difficulty initiating urine stream are all early signs of benign prostatic hypertrophy. Hematuria may occur as a later sign.
The nurse is assisting in participating in a prostate screening clinic for men. The nurse questions each client about which sign of prostatism? a) ability to stop voiding quickly b) absence of postvoid dribbling c) excessive force in urinary system d) hesitancy when initiating urinary stream
D- Signs of prostatism that may be reported to the nurse are reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating quickly, a sensation of incomplete bladder emptying after voiding, and an increase in episodes of nocturia. These symptoms are the result of pressure of the enlarging prostate on the client's urethra.
A client with acute renal failure is having trouble remembering information and instructions as a result of altered laboratory values. The nurse avoids doing which of the following when communicating with this client? a) giving simple, clear directions b) including the family in discussions related to care c) explaining treatments using understandable language d) giving thorough and complete explanations of treatment options
D- The client with acute renal failure may have difficulty remembering information and instructions because of anxiety and altered laboratory values. Communications should be clear, simple, and understandable. The family is included whenever possible. Information about treatment should be explained using understandable language.
A nurse is assessing the renal function of a client. The nurse checks which item as the best indirect indicator of renal status? a) bladder distention b) level of consciousness c) pulse rate d) blood pressure
D- The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. In order for kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The pulse rate affects the cardiac output, but can be altered by factors unrelated to kidney function. Bladder distention reflects a problem or obstruction that is most often distal to the kidneys. Level of consciousness is an unrelated item.
45. A nurse is urging a client to cough and deep breathe after nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is likely a result of: a) a stress response to the ordeal of surgery b) a latent fear of needing dialysis if the surgery is unsuccessful c) effects of circulating metabolites that have not been excreted by the remaining kidney d) pain that is intensified because the location of the incision is near the diaphragm
D-After nephrectomy the client may be in considerable pain. This is a result of the size of the incision and its location near the diaphragm, which makes coughing and deep breathing so uncomfortable. For this reason, opioids are used liberally, and may be most effective when provided as patient-controlled analgesia, or through epidural analgesia. Options A, B, and C are not specifically related to this client's situation.
Diuretic's Definition: Nursing interventions :
Definition: Drugs that act to increase the flow of urine. Purpose is to increase net loss of water. To do this they act on the kidney to increase excretion of sodium. Nursing Interventions Diet I&O Urine output Respond to BP Electrolytes Take pulse Ischemic episodes or TIAs Complications: CVA, CAD, CHR, CRF
Pyelonephritis: Acute/ Chronic inflammation- renal pelvis and parenchyma or kidney. Mild malaise or sudden onset of chills, fever, vomiting, flank pain, dysuria, and frequent urination
Diagnose: CBC, UA, Urine culture (↑WBC, RBC) Complications: septic shock- bacteremia, and kidney failure *Antibiotics, Determine cause!! Glomerulonephritis: Usually follows streptococcus infection- strep throat, scarlet fever, rheumatic fever Bacterial, Viral , and Puss formation- inflammation due to decreased immune system Signs and Symptoms also include edema on the eyes and ankles
Wilms Tumor Clinical Manifestations: Abdominal swelling or distention, Pain, fever, hematuria, hypertension
Diagnosis: Ultrasound, Renal arteriography Treatment: Nephrectomy, Radiation, Chemo Responds well to mulimodality therapy
Diverticular Disease
Diverticula Saclike projections of bowel mucosa thru the muscular layer of the colon Diverticulosis The presence of diverticula. Usually asymptomatic. May have lower quadrant pain, constipation or diarrhea Treatment High fiber diet, avoid foods with small seeds
Stool Softeners
Docusate (Colace, Surfak, Doxidan) Action: Softens the stool by drawing water into it and forms a fat and water emulsion Use: Constipation Route: PO in the morning or evening Side Effects: Diarrhea, Nursing Implications: -Do not give with 1 hour of other medications -Teach the client that this medication should not be taken for more than 1 week -Encourage fluids
5-ALPHA-REDUCTASE INHIBITORS
Dutasteride (Avodart), Finasteride (Proscar) Action: Decreases the production of testosterone in the prostate gland Use: Treatment of benign prostatic hyperplasia Side Effects: Sexual dysfunction, decreased libido, Nursing Implications: Monitor PSA levels
Assessment Abnormalities:
Dysuria - painful or difficult urination Frequency - increased urination Enuresis - involuntary nocturnal urination Hesitancy - Difficulty or delay in starting urination Urgency - strong desire to urinate immediately Hematuria - blood in urine Burning with urination - "stinging" pain in urethra with urination Retention - inability to urinate even though bladder contains urine Incontinence - inability to voluntarily control urination Stress incontinence - involuntary urination with stress (ex. Coughing, sneezing, laughing) Nocturia - frequency of urination at night Polyuria - large volume of urine within a given time Anuria - no urination - less than 100ml in 24 hours Oliguria - diminished amount of urine - 100 to 400ml in 24 hours
Glucose
From 70 to 99 mg/dL Normal fasting glucose From 100 to 125 mg/dL Prediabetes 126 mg/dL Diabetes
Bulk-producing Laxatives:
Give with full glass of water Causes water to be retained within the stool Increases bulk - stimulates peristalsis Onset 12-24 hours - may be as long as 72 hours Usually considered to be safest Must have adequate fluid intake - otherwise could cause obstruction Metamucil
Hematocrit Male: Female:
Hematocrit is often performed as part of a CBC, results from other components are taken into consideration. A rise or drop in the hematocrit must be interpreted in conjunction with other parameters, such as RBC count, hemoglobin, reticulocyte count and/or red blood cell indices. Men: 40%-55% Women:36%-46% Cause ↑ Kidney tumor Cause ↓ Kidney failure
A nurse is caring for a client who was brought to the emergency room following an accident. The nurse suspects a ruptured bladder.Which of the following is consistent with this diagnosis?
Hematuria Rationale: The cheif manifestation of a ruptured bladder are hematuria (blood in the urine), pelvic pain, and oliguria (low urine output).
Dialysis: Diffusion of solutes from higher to lower concentration across a semi permeable membrane
Hemodialysis Arteriovenous fistula (AV fistula) Continuous Renal Replacement Therapy (CRRT) Peritoneal dialysis Continuous Ambulatory Peritoneal Dialysis Hemodialysis - Nursing Care Assessment, Vital signs, Diet, Laboratory, Medications
Celiac Disease: Inability to absorb nutrients such as fats and peptides contained in gluten
Hereditary & metabolic disorder Clinical manifestations: Abdominal distension, Vomiting , Diarrhea, muscle wasting & extreme lethargy Treatment High calorie, high protein, gluten free diet
Saline Laxatives:
Hypertonic compounds - draw water into intestine from surrounding tissue May cause dehydration & electrolyte imbalance. Works within 1-3 hours Magnesium Citrate - used bowel prep
Benign Prostatic Hyperplasia
Increase in size of prostate gland Clinical Manifestations: decreased ability to void, starting stream, incomplete emptying. Early sign is nocturia Complications: Increased risk of infection & calculi, urinary retention, hydronephrosis, pyelonephritis, obstruction. Diagnosis: Digital rectal exam, urinalysis (urinary infection), PSA, uroflowmetry Medications: Finasteride (Proscar) shrinks prostate, Alpha1 Blockers: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax): relax smooth muscle Surgery: TURP: prostate tissue removed thru urethra Complications include: retrograde ejaculation or transurethra syndrome (fluid volume excess with hyponatremia)
Diverticulitis Disease
Inflammation and/or perforation of a diverticulum Manifestations - Pain - Constipation/Diarrhea - Nausea/Vomiting - Low-grade fever Management - Low roughage diet - Bowel rest & antibiotics during acute episodes - Surgery
Carbonic Anhydrase Inhibitors
Inhibits carbonic anhydrase: an enzyme that affects acid-base Also has indications for use as an anticonvulsant and treating motion sickness Not commonly used: weak diuretic, can contribute to metabolic acidosis Acetazolamide (Diamox), methazolamide (Neptazane)
ANTIDIARRHEAL: Absorbants and Protectants
Kaolin and Pectin (Kaopectate) Charcoal Bismuth Subsalicylate (Pepto-Bismol) Action: Bind substances that cause diarrhea Use: Diarrhea Route: PO 1 hour before or 2 hours after other medications Side Effects: Constipation, darkening of tongue and stool Nursing Implications: -Bismuth subsalicylate also has antimicrobial effects -Inform client not to take if on ASA or to take ASA while using bismuth subsalicylates -Assess for contraindications, such as chronic inflammatory bowel disease
Osmotic and Saline Laxatives/Cathartics
Lactulose (Cholac, Heptalac) Sorbitol Magnesium Hydroxide ( Milk of Magnesia) Magnesium Citrate Polyethylene glycol (Klean - Prep) Action: Stimulates peristalsis by irritating the bowel mucosa or by drawing water into the intestine which increases stool volume & decreases the consistency of stool. Works in 3-6 hours. Use: Short term use for constipation Route: PO with full glass of water Side Effects: Diarrhea, Nausea, Nursing Implications: -Daily I & O's and weight, Monitor fluids and electrolytes
A nurse is caring for a younger adult client who sustained massive damage to the bladder. An emergency cystectomy and ileal conduit was performed. After viewing the appliance for the first time, the client tells the nurse, "Well, I guess my sex life is over now." The most therapeutic response from the nurse would be which of the following?
Lets talk about why you feel that way. Rationale: In the therapeutic response the nurse acknowledges the client's feelings first and offer's to discuss the client's concerns. The nurse knows that ostomates live full, active and happy lives (including sexual expression) with ileal conduits and external appliances
Lubricant Laxatives:
Lubricate intestinal wall and soften stool Onset of action 6-8hrs, but may be up to 48 hrs - depends on pt's normal GI transit time Does not increase peristaltic action May inhibit absorption of fat-soluble vitamins Oil can be aspirated into lungs causing lipid pneumonia Mineral Oil
CATHARTICS : Bowel Preparation Cathartics
Magnesium Citrate (Citrate of Magnesia, Citro-Nesia, Citroma) Polyethylene Glycol and Electrolytes (Colyte, GoLYTELY, X-Pre Action: Promotes evacuation of the bowel Use: Most generally used as a bowel prep. Route: PO Side Effects: Abdominal cramping, nausea, vomiting Nursing Implications: -Observe for electrolyte imbalance and dehydration -Do not give in the late evening as this will affect sleep pattern -Stool should be free and clear of solid matter -Chilling the solution before administration makes it more palatable
urinary system
Maintains & regulates the body's internal environment Excretes metabolic wastes Excretes or conserves water and solutes as needed Regulates acid base balance and blood pressure Endocrine function: production of renin & erythropoietin and activation of vitamin D Any disorder of the urinary system can affect the entire body!
Creatinine
Male 0.9 - 1.3 mg/dL Female 0.6 - 1.1 mg/dL ↓creatinine levels: Typically no concern ↑ Creatinine level: glomerulonephritis, pyelonephritis, acute tubular necrosis, Prostate disease, kidney stone, urinary tract obstruction, complication w/diabetes
Fecal Incontinence Manifestations Loss of voluntary control of defecation
Management: Directed at cause Measure to either reduce diarrhea or constipation Exercises for pelvic floor muscle tone Bowel retraining program Establish daily routine for bowel evacuation - Daily bowel evacuation time - Glycerine suppository use (with care!) - Caring, nonjudgmental manner
Constipation Pathophysiology Organic cause—tumor or partial bowel obstruction Lifestyle and psychogenic causes Habitual use of laxatives
Manifestations Fecal impaction, Watery mucus, Full sensation in rectum with abdominal cramping Management Digital exam of rectum Diagnostic tests Dietary management Medications Enemas
Urinary Tract Tumors: (Can be bladder or kidney) Risk Factors: Males, Age (over 50), Carcinogens in the urine, Chronic inflammation or infection of bladder Chemicals: cigarette smoke, spray paint, hairdresser supplies, ect
Manifestations: Painless hematuria, Frequency, Urgency, Dysuria, Obstruction (late problem as is pain) Treatment: Medications: chemo instilled into the bladder Surgery: TURBT: Transurethral resection of bladder tumor, Cystectomy (partial or complete), Cutaneous ureterostomy, Ileal conduit, Continent ileostomy (Koch's pouch) Nursing Care: Assessment: Output of less than 30mL/hr must be reported! Closed drainage systems - label all tubes Assess catheters frequently FF: 3000 mL/day Encourage activity
Lubricants
Mineral Oil Action: Prevents water reabsorption by forming oily coat on feces which results in softening of feces Use: Constipation Route: PO at bedtime Side Effects: Over usage may cause deficiency of fat-soluble vitamins, Nausea, Oily after taste Nursing Implications: -Instruct client not for long term use, Assess for vitamin deficiency as needed, Do not give with wetting agents or stool softeners
INR
Norm: 0.8 to 1.2
Specific gravity
Norm: 1.005 - 1.030
PT (prothrombin time)
Norm: 10 to 13.5 seconds ↑ than 14seconds: liver disease, vitamin K deficiency, anticoagulation drug (warfarin) therapy, severe liver disease A prolonged PT means that the blood is taking too long to form a clot.
Sodium
Norm: 135-145 mEq/L ↑ Sodium level hypernatremia: dehydration, Cushing syndrome, or diabetes insipidus. ↓sodium levels hyponatremia: edema, Addison's disease, diarrhea, diuretic administration, kidney disease, nephrotic syndrome,
platelets
Norm: 150,000 and 450,000 platelets per microlite ↓ 150,000 thrombocytopenia ↑ 450,000 thrombocytosis
PTT
Norm: 25 to 35 seconds longer than 35 sec. indicates- Disseminated intravascular coagulation, Hemophilia A or B, Liver disease, Malabsorption, Vitamin K deficiency, Von Willebrand's disease
APTT
Norm: 25-35seconds Prolonged APTT + Prolonged PT= Vitamin K deficiency, Liver disease, thrombolytic therapy, Heparin, Warfarin, Coumadin
potassium
Norm: 3.5-5.5 mmol/L ↑ potassium levels: Acute or chronic kidney failure, Addison's disease, Diabetes ↓Decreased potassium levels: diarrhea & vomiting, Hyperaldosteronism, complication of acetaminophen overdose, In diabetes, the potassium level may fall after someone takes insulin, potassium-wasting diuretics
urine pH
Norm: 4.5 - 8
BUN ( blood urea nitrogen)
Norm: 5-20 ↑20 BUN levels suggest impaired kidney function.
Surgery Lithotripsy: crushing the stones with sound or shock waves Extracorporeal shock-wave lithotripsy (ESWL) Shock waves outside the body Percutaneous Lithotripsy- Stone fragmented using ultrasonic transducer or laser beam after nephrostomy (nephroscope inserted to visualize renal pelvis) Cystoscopy: Removal or crushing of stones in bladder Nephrostomy: Flank incision and use of nephroscope to see the renal pelvis then stones can be removed or crushed. Nephrolithotomy: Surgical removal of stone, may require a Nephrectomy Nephrectomy:Removal of kidney
Nursing Care: Assessment of S/S, pain Assess output and characteristics of urine Strain ALL urine Increase fluids and activity - IF not contraindicated Maintain patency of all catheters Education: Minimize the risk for future stones Drink 2.5 - 3 quarts of fluid / day Follow dietary recommendations Take medications as prescribed Prevention, recognition, and treatment of UTIs
Urinary Calculi: Formation of stones, Keep urine dilute and free flowing Categories of stones: calcium phosphate, calcium oxalate, uric acid, cystine, struvite Most common: Calcium Manifestations: Pain occurs when obstruction to urinary flow Abdominal or flank pain (often severe!) Hematuria, Renal colic, N/V, diaphoresis, pallor Location of stones Type of pain depends on where stone is and if it is obstructive
Obstruction in urinary tract - emergency Risk Factors: Males, family history, intestinal bypass surgery, immobilization, recurrent UTIs Etiology: Metabolic, Dietary, Climate, Genetic, Lifestyle Prevention: Keep urine dilute and free flowing, Possible dietary changes Medications: Narcotics for pain, Possibly: Thiazide diuretics to decrease urinary calcium and help prevent future stones Dietary Management: Increase fluid intake, May limit dietary calcium and vitamin D enriched foods, May modify diet to make urine more acid (lower the pH
ANTIDIARRHEAL: Synthetic Hormones
Octreotide Acetate (Sandostatin) Action: Slows intestinal mobility by stimulating GI tract absorption of fluids and electrolytes Use: Chronic diarrhea associated with certain tumors and HIV Route: Subcutaneous between meals and at HS Side Effects: Dizziness, Drowsiness, Fatigue, Headache, Weakness Nursing Implications: -Administer slowly SQ -Do not use solution if discolored or has particulates -Not for use in women who are pregnant
Total proctocolectomy with permanent ileostomy
One-stage operation involving the removal of the colon, rectum, and anus with closure of the anus. End of terminal ileum is brought out thru abd wall to form a stoma (ostomy) Ostomy usually at right lower quadrant below belt line
Ileostomy
Opening in ileum to drain waste products from the small intestine. Regularity can not be established. Pouch must be worn at all times. Drains liquid fecal material which is irritating to the skin. Watch for dehydration Provide emotional support - normal for pt to avoid looking at and working with ostomy at first Prevent skin problems - output increased in enzymes & bile salts
Osmotic Diuretics
Osmotic force to pull water into the nephron to increase the excretion of nearly all electrolytes in the proximal tubule and the loop of Henle Has very specific applications, can worsen edema Decreases cerebral edema Mannitol (Osmitrol), urea (Ureaphil), glycerin
A nurse is caring for a client who just had a transurethral resection of the prostate (TURP). Which of the following should the nurse remind the client to report to the provider?
Painful urination Rationale:The client should notify the provider of any signs of urinary tract infection, such as fever, urinary frequency, or painful urination.
Hernia
Pathophysiology Protrusion of an organ or structure through the muscular wall of the abdomen Described by location Pain radiating to groin, Reducible, Irreducible, Incarcerated, Strangulated Management Diagnosis made if able to reduce or manipulate, Surgery
Diarrhea Increase in stool frequency Increase in stool volume Increase in stool looseness NOT A DISEASE BUT A SYMPTOM Pathophysiology Result from impaired water absorption or increased water secretion into the bowel, Increased water absorption: increased peristalsis or decreased bowel surface, Increased water secretion: osmosis, infection, unabsorbed fat, medications
Pathophysiology: Manifestations Depend on the cause, duration, severity, and area of bowel affected Complications Loss of water and electrolytes Dehydration, hypovolemic shock Potassium, magnesium, and bicarbonate loss can lead to metabolic acidosis Evaluation: Stool frequency, Nutritional status, Weight, Fluid volume status, Skin integrity, Monitor electrolytes Management Identify and treat underlying cause, Diagnostic tests, Dietary management, Medications Foods that may Aggravate Chronic Diarrhea.
A nurse is reinforcing education on prostate health to a client. Which of the following statements is an appropriate statement for the nurse to make regarding a PSA test.
The PSA should not be given within 48hrs of a rectal exam. Rationale: PSA is a glycoprotein that is found only in cytoplasm of the epithelial cells of the prostate.
A nurse is caring for a client with chronic kidney disease. The nurse anticipates that the provider will prescribe a diet that has which of the following restrictions?
Protein Rationale: Chronic kidney disease is irreversible loss of kidney ability to excrete waste, concentrate urine, and conserve electrolytes. A diet low in protein supplies only essential amino acids reducing the amount of metabolic waste products and may help to preserve a degree of kidney function.
Total proctocolectomy with continent ileostomy - Kock pouch
Pt does not need an external pouch over stoma Stoma covered with a cap or dressing Internal pouch made in the distal segment of the ileum and a one-way nipple valve is created and sutured into place at the abdomen. Pouch acts as reservoir and is drained at regular intervals by insertion of a catheter
A nurse is caring for a client who has a diagnosis of renal calculi. Which of the following is a priority nursing action?
Relieve Pain Rationale: The pain associated with renal calculi is severe and should be addressed immediately.
Chronic Renal Failure Slow, insidious process, Final stage is end-stage renal disease (ESRD) Stages of Chronic Renal Failure Decreased renal reserve - No S/S
Renal insufficiency - BUN and serum creatinine levels are elevated. GFR is < 20% of normal. No symptoms until 75-80% of kidney function is destroyed. S/S include fatigue, weakness, headache, nausea, pruritis, uremic encephalopathy - due to nitrogen in the blood - can cause confusion. End stage renal disease - Uremia develops. GFR is <5% of normal. Difficulty carrying out ADL's Diagnostic tests: Serum creatinine, BUN, Creatinine clearance, Serum electrolytes, ABGs, CBC, Urinalysis Kidney biopsy
Colorectal Cancer
Risk Factors • Age - usually occurs after the age of 50, Family history, Polyps, IBD, Smoking/ Alcohol consumption, Physical inactivity, Obesity Diet - high saturated fat, low-fiber, inadequate fruit and vegetables Manifestations Bleeding with defecation Change in bowel habits Pain, anorexia, weight loss Prognosis depends on extent of the disease
Acute Renal Failure Rapid decline in function. Progressive Azotremia (accumulation of nitrogenous products such as BUN). Increased levels of serum creatinine. Abrupt onset. Often reversible with treatment
Risk factors: Major trauma, surgery, infection, hemorrhage, severe heart failure, lower urinary tract obstruction, Older adults at risk Causes: Prerenal , Hypovolemia and Congestive heart failure, Intrarenal , Acute damage to nephrons , Postrenal, Obstruction of urine outflow Three phases of acute renal failure: 1. Initiation 2. Maintenance 3.Recovery
Prostate Cancer
Risk factors: age, race (African-Am), family history, chemical exposure, high in fat, high serum testosterone levels Manifestations: Early - no symptoms, later - symptoms of urinary obstruction, metastasis and general symptoms are seen. Complications: spinal fractures, anemias, and death Diagnosis: Annual digital rectal exam and serum PSA after age 50 (sooner w/risk factors), Transrectal ultrasonography, tissue biopsy, Bone scan, MRI, CT Treatment: hormone therapy by remove the testes (orchiectomy) or with drugs to block effects of testosterone and/or radiation
Testicular Cancer
Risk factors: between ages of 15 - 40, cryptorchidism (undescended testicle), family history. Most have no risk factors Clinical Manifestations: usually only one side, painless hard nodule Diagnosis: blood draw for tumor markers, ultrasound, biopsy Treatment: surgery, radiation therapy
Hydronephrosis: Abnormal dilation of renal pelvis & calyces Results from obstructions or backflow of urine
S/S: depend on how rapidly it develops Acute - colicky pain that may radiate into the groin, hematuria, pyuria, fever, nausea, vomiting, abdominal pain Chronic - intermittent dull flank pain, hematuria, pyuria, fever, palpable mass Diagnosis: Ultrasound, CT scan, Cystoscopy Treatment: Stents Nursing Care: Maintain & assess urinary drainage
Lactose Intolerance: Sensitivity disorder, inadequate production or defect in the lactace enzyme
Sensitivity disorder, inadequate production or defect in the lactace enzyme Inability to digest lactose Clinical Manifestations: Bloating, nausea, flatus, diarrhea, abdominal cramping Treatment: Lactose free diet or a lactose enzyme can be given
Treatment for bowel tumors
Surgery - remove tumor Right hemicolectomy - when cancer is located in the cecum, ascending colon, hepatic flexure, or transverse colon to the right of the middle colic artery. Portion of the terminal ileum, ileocecal valve, and appendix removed and an ileotransverse anastomosis performed Left hemicolectomy - resection of the left transverse colon, splenic flexure, descending colon, sigmoid colon, & upper portion of rectum Radiation therapy & Chemotherapy Chemotherapy with positive lymph nodes or metastatic disease
A nurse is caring for a client with suspected acute renal failure who is to undergo a renal biopsy. Which of the following positions should the nurse assist the client into?
The client is positioned prone with a pillow elevating the abdomen. A renal biopsy is the insertion of a needle into the kidney just below the twelfth rib to obtain diagnostic specimens.
Irritable Bowel Syndrome (IBS) Manifestations of IBS Abdominal pain and tenderness, (Often in right lower quadrant) Intermittent and colicky or dull and continuous, May be relieved by defecation, Alternating constipation and diarrhea, (stool may contain mucus) Abdominal bloating and flatulence, Possible nausea, vomiting Management History and Physical Diagnostic tests: Stool specimen, Sigmoidoscopy Colonoscopy, Small-bowel series
Treatment: Relieve symptoms, Reduce or eliminate precipitating factors, Medications, Fluids, Fiber, Eliminate "trigger" foods Nursing Care: Depends on the clients symptoms Teaching, Symptoms are real, Discuss related factors, Relationship between stress and manifestations, Stress reduction techniques, Psychological factors, Dietary influences, Exercise, Dietary patterns, Notification of PCP with any changes, Fecal Incontinence
Acute Glomerulonephritis Inflammation of glomerulus Most common disease of kidney Usually follows strep throat infection Clinical Manifestations: Flank pain, fever, loss of appetite, malaise, Hypertension, fatigue, Eyes & ankles may be edematous, Oliguria (scant output - less than 400cc/24hours), Hematuria (rust-colored, dark brown), UA may show albuminuria (blood protein and casts in urine), Elevated BUN and serum creatinine
Treatment: Supportive, Antipyretic, Diuretic (Lasix), Antihypertensives, Diet - restrict sodium, proteins, fluids May need antibiotics - penicillin (Treat strep infection) Corticosteroids such as prednisone to help reduce the risk for renal failure Plasmaphoresis - 150-400 ml of blood removed & put in cell separator, Blood divided into plasma & formed elements, Formed elements are mixed with a plasma replacement & returned to the pt Prognosis good Repeated occurrence can lead to chronic glomerulonephritis
Ulcerative colitis: - Chronic inflammatory disease starting at the rectum - Affects mucosa and submucosa of the rectum and colon - Common to be diagnosed before age 30, in Jews and Whites, men and women; urgency to defecate, mucossy stools- frequent (10-20days) - Weight loss, fever, malaise, diarrhea can alternate with constipation, watery stools contain blood, mucous, & pus from mucosal ulcerations
Treatments: To induce and maintain remission and improve quality of life. Diet: Well-balanced without irritating foods. Low-fat, high proteins, vitamins, and minerals. May need TPN. Meds: Anticholinergic drugs. Only occasional antidiarrheal are used. Sulfasalazine used in mild to moderate cases. Corticosteroids used in severe cases. - Common: Flagyl - Common: Corticosteroid+ Amino salicylate - Sulfasalazine= Antibiotic + Anti-inflammatory - Rare- Surgery- Remove colon +rectum- severe hemorrhage Or perforation- followed by ileostomy or ileo-anal anastomosis - Physical and Psychological Rest
Crohn's Disease: Chronic relapsing inflammatory disorder -All layers of bowel inflamed w/edema -Any of the GI tract can be affected -Chronic diarrhea w/crampy intermittent abdominal pain, often in lower right quadrant -weight loss, malaise, nausea, anorexia, fever -If an obstruction occurs then abdomen may be tender and distended w/vomiting blood and stool, malnutrition, fissures, and fistulas
Treatments: to treat flair ups and maintain remission Diet:↑minerals, vitamins, calories, and protein and ↓irritating foods. TPN may be necessary. Meds: Anticholinergics & Narcotics relieve cramping and diarrhea. If bacteria is involved, sulfasalazine (antibacterial & Anti-inflammatory). Corticosteroids & immunosuppressive drugs reduce inflammation and promote healing. Surgery for obstruction, GI hemorrhage, abscesses, or perforation. Last resort colostomy, ileostomy following re-sectioning.
Total colectomy and ileal reservoir
Two procedures performed about 8-12 weeks apart 1st - colectomy, rectal mucosectomy, ileal reservoir construction, ileoanal anastomosis, & temporary ileostomy 2nd - closure of the ileostomy which functionalizes the reservoir
Urine Studies
UA, Culture and Sensitivity, 24 hour Urine Tests
Voiding Studies
Uroflowmetry, Cystometrogram or Voiding cystogram
Malabsorption
Usually occurs with small intestine disorders Celiac disease Lactose intolerance Short bowel syndrome Manifestations of Malabsorption Anorexia, Abdominal bloating Diarrhea: loose, bulky, foul-smelling stools Steatorrhea (fatty stools) Weight loss Weakness, general malaise Muscle cramps, bone pain Abnormal bleeding, anemia Management: Find and treat cause
A nurse is caring for a client with acute pyelonephritis. Which of the following is an appropriate response by the nurse regarding home care.
You should complete the entire cycle of antibiotic therapy. Rationale: It is important that the client take the full prescription of antibiotic therapy to decrease the chance of regrowth of the causative organism.
Total proctocolectomy (colectomy)
may remove entire colon, rectum, and anal sphincter Will need ileostomy. Oral or parenteral antibiotics pre-op (neomycin sulfate) as bowel antiseptic to decrease risk of infection from bowel, cleansing of bowel - enemas, laxatives
A nurse is caring for a client receiving peritoneal dialysis and notes a brownish tinge to the dialysate output. The nurse interprets that this finding could be a result of: a) early infection b) insufficient fluid instillation c) bladder perforation d) bowel perforation D- Brown-tinged or bloody drainage could indicate
perforation of the bowel by the peritoneal dialysis catheter. If noted, this must be reported to the physician immediately. Early signs of infection include cloudy dialysate output or fever and, most likely, abdominal discomfort. Bladder perforation could yield yellow or bloody drainage. Insufficient fluid instillation is an incorrect option. The client would have no signs as a result of insufficient fluid instillation except outflow of smaller amounts of dialysate.
