Care of Adults Exam 2 Review

What does it mean when protein is found in the urine

(GN) Inflamed glomeruli allowing the passage of protein and blood in the urine, decline in kidney function and impaired elimination

For the pt with AKI who does not require dialysis the RDN will calculate the pts caloric and protein needs using?

0.6g/kg of body weight or 40 g/day

Pts with AKI who require dialysis the protein level needs to range from?

1-1.5 g/kg

ESKD GFR

15

Stage 4 GFR

15-29

Stage 5

15?

Nephrosclerosis is rarely seen when BP is consistently below?

160/110

Tinidazole can be used as an alternative for Metronidazole for Giardiasis as well. Stools are examined for how long after treatment to ensure drug effectiveness?

2 weeks

A dilution no greater than 1 mEq (mmol/L) of potassium to 10 mL of solution is recommended for IV administration. The maximum recommended infusion rate is 5 to 10 mEq/hr (mmol/hr); this rate is never to exceed

20 mEq/hr (mmol/hr) under any circumstances. In accordance with National Patient Safety Goals (NPSGs), potassium is not given by IV push to avoid causing cardiac arrest

sTAGE 3 GFR

30-59mL

Pts with NS have low albumin levels of less than?

3g/dL

Leflunomide is prescribed with a loading dose for 3 days followed by a lower dose after. Teach the pt the drug takes?

4-6 weeks and up to 3 months before peak benefit is realized

Patients with GN may have an increased protein excretion rate from ____ to ____ with decreased

500mg to 3G per 24hr, serum albumin levels from protein lost in the urine or fluid retention causing dilution

Pts taking Hydroxychloroquine should have an eye exam before taking the drug and every?

6 months after to detect changes to the cornea, lens, or retina

If high potassium levels are found in a pt with AKI potassium is restricted to?

60-70 mEq/kg

The 2nd stage of CKD GFR is?

60-89

Pts with AKI dietary sodium ranges from?

60-90 mEq/kg

Normal GFR

90-120

Peritoneal lavage is

A diagnostic test in which rinse solution is inserted and then removed from the peritoneal cavity to detect traumatic damage

NS treatment

ACEI, Statins, Heparin, Diet changes, Diuretics, Sodium restriction,

Liver enzymes

ALT (Alanine Transaminase) 8-20 units/L AST (Aspartate Transaminase) 5-40 units/L ALP (Alkaline Phosphatase) 42-128 units/L Total protein 6-8 gm/dL Serum Creatinine 0.6-1.2, 0.7-1.4

IF ACEI not tolerated use?

ARBs

Myxedema S/S

Accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues which causes puffiness, periorbital edema, masklike effect

AKI may be avoided if?

Adequate blood flow to the kidney is maintained

Etanercept is a BRM that is self administered teach pts to report site reactions because this may indicate?

An allergic response

Pts taking MTX are at risk for infection and should be taught to?

Avoid crowds and alcoholic beverages to prevent liver toxicity

Teach pts receiving BRMs to?

Avoid live vaccines, crowds, and sick people

Non-weight-bearing fractures of the pelvis such as the Pubic Rami, and Iliac crest can be minimal ranging from?

Bedrest on a firm mattress or bed board, pain management, stool softener

Teach pts taking Leflunomide to report changes in hair, BMs, WBC/platelet/Liver enzyme counts and to avoid alcohol. Make sure to inform them the drug can cause?

Birth defects

Thioamides MOA

Block TH production by preventing iodide binding in the thyroid gland

Pelvic fractures are concerning because?

Blood loss, hypovolemic shock

Rituximab is a monoclonal antibody to

CD20 on B-cells, activation of CD20 causes apoptosis of the B-cell, observe for infusion reactions this drug has a black box warning related to opportunistic pathogens leading to hospitalizations and death

Infliximab is a BRM TNFA inhibitor that is not refrigerated and may cause?

Chest pain and dyspnea during infusion which may indicate anaphylaxis monitor BP and infusion site

Pts with Strep should be taught to?

Complete entire course of antibiotics

If pregnancy is desired for the pt receiving MTX instruct the pt to?

Consult with a rheumatologist and OB/GYN provider. They'll recommend stopping MTX 3 months prior before planning pregnancy.

Metformin must be continue at least 24 hours before any study using?

Contrasts media can be done due to life threatening lactic acidosis

BRM financial downsides?

Cost very expensive and insurance typically won't pay completely for their use

Chronic steroid therapy can result in?

DM, HTN, Osteoporosis, Glaucoma, Fluid & Electrolyte imbalances, impaired immunity

Iodine preps may be used for short term therapy for hyperthyroidism patients before surgery to?

Decrease blood flow through the thyroid gland reducing TH improvement occurs in 2 weeks but it may be week before metabolism returns to normal

Pts taking MTX should be monitored for?

Decreased WBCs and platelets ( resulting from bone marrow suppression)

After Nephrostomy monitor the pt for complications such as?

Decreased or absent drainage, cloudy or foul smelling drainage, leakage, notify surgeon

Aminosalicylates

Decreases inflammation by suppressing inflammatory cytokines, teach avoid exposure to sunlight when taking sulfasalazine •Sulfasalazine •Mesalamine

Beta blocking drugs such as Propranolol may be used for supportive therapy to relieve?

Diaphoresis, anxiety, tachycardia, palpitations, but don't inhibit TH production

Leflunomide may be prescribed for pts its a slow immune modulating drug used to?

Diminish inflammation, joint swelling, and stiffness improving mobility

Broad Spectrum Antibiotics such as Metronidazole in conjunction with Trimethoprim/Sulfamethoxazole (TMZ) or Ciprofloxacin may be prescribed to pts with?

Diverticulitis

Oral potassium preparations may be taken as liquids or solids. Potassium has a strong, unpleasant taste that is difficult to mask, although it can be mixed with many liquids. Because potassium chloride can cause nausea and vomiting, give the drug?

During or after a meal and advise the patient using the drug at not to take it on an empty stomach

NS can be prevented with treatment preventing progression to?

ESKD

Which finding would the nurse expect when assessing a child with acute poststreptococcal glomerulonephritis?

Edema, Dyspnea, S3 Sound (gallop), Smoky Coca Cola urine, Dysuria, Oliguria, fatigue, lack of energy, nausea, vomiting, uremia, mild to moderate HTN from fluid and electrolyte balance and sodium retention, JVD

BRM drugs

Etanercept, Infliximab, Adalimumab, Anakinra, Abatacept, Rituximab, Golimumab, Tocilizumab

Hyperthyroidism S/S

Exophthalmos (wide eyes), edema in the extraocular muscles, eyelid lag (retraction), globe (eyeball) lag (look down and then up) upper eyelid pulls back faster than eyeball, bruits, tachycardia, dysrhythmias, fine soft silky smooth warm moist skin, thinning hair, weakness, hyperactive DTR, tremors, fatigued, irritable

Complex pelvic fractures with extensive soft tissue damage may require?

External fixation

Golimumab is a TNFA inhibitor teach pts to report signs of?

Fever, malaise, avoid live vaccines, crowds, alcohol, and teach about HTN, GI distress

Kidney functions

Filtering water and waste from the bloodstream, maintain body fluid volume, create urine waste elimination, regulate BP, acid base balance, produce erythropoietin for RBC synthesis, and convert Vitamin D to it's active form (Calcitriol)

Tocilizumab IL-6 inhibitor when used teach pts the importance of?

Frequent Liver enzyme, WBC and Platelet checks

Older adults have a decline in?

GFR

Which laboratory test provides evidence consistent with a client having renal impairment?

GFR

ALOL1 allele is seen in African ancestry an is a risk factor for?

GN

Medications for glomerulonephritis and nephrotic syndrome

GN- Erythromycin (Strep), NS- Steroids, Cytotoxic immunosuppressive agents (Rituximab), Diuretics, ACEI, Heparin, Statins,

Metronidazole is the drug of choice for?

Giardiasis

Kidney issues most commonly caused by?

HTN, DM

GN is associated with

HTN, Kidney damage leading to CKD, Edema, , Anemia, Hypercholesterolemia

Leflunomide is a potent drug tolerated generally with side effects of?

Hair loss, diarrhea, decreased WBCs and platelets, or increased liver enzymes

Metronidazole in conjunction with trimethoprim/sulfamethoxazole (TMZ) or ciprofloxacin usually prescribed for diverticulitis

Helpful in patients with Fistulas, anorectal abscess and infection related to Crohn's

Respiratory function is performed how often for severe hypokalemia?

Hourly

Potassium is a severe tissue irritant and is never given by IM or subcutaneous injection. Tissues damaged by potassium can become necrotic, causing loss of function and requiring surgery. IV potassium solutions irritate veins and cause phlebitis. Check the prescription carefully to ensure that the patient receives the correct amount of potassium. Assess the IV site

Hourly and ask the patient whether he or she feels burning or pain at the site

Pts with a history or present illness of cardiac disease and dysrhythmias should not use?

Hydroxychloroquine

Immediately report a temperature increase of even 1 in patients with what suspected disease?

Hyperthyroidism

Diuretics that increase the kidney excretion of potassium can cause hypokalemia, especially high-ceiling (loop) diuretics (e.g., furosemide and bumetanide) and thiazide diuretics. These drugs are avoided in patients with

Hypokalemia

During AKI with high volume urine output the main problems are?

Hypovolemia, dehydration, electrolyte loss

Anakinra is a

IL-1 receptor antagonist, monitor WBC count, report respiratory symptoms such as cough and fever, and can cause tumors

The nurse is reviewing the client's laboratory data prior to a nephrostomy tube insertion. Which data requires the nurse to take action?

INR 2.1

Myxedema treatment

IV saline, glucose, levothyroxine IV, respiratory support

If acute inflammation is present in pts with RA may use what nonpharmacologic interventions?

Ice, paraffin, hot packs, plasmapheresis

Elevated BUN and Creatinine indicate?

Impaired elimination

The first stage of CKD has a GFR greater than 90 with a risk for kidney damage with?

Infection, inflammation, pregnancy, dehydration, hypotension

Moderate short term tapering of glucocorticosteroid bridge therapy may be used when?

Inflammation is symptomatic and other RA medications are insufficient or have not yet had any effect

Biologic and Targeted Therapy

Inhibits cytokine tumor necrosis, prevents leukocyte migration from blood stream to inflamed tissue, expensive but doesn't work for everyone, (Infliximab, adalimumab, certolizumab pegol, golimumab, natalizumab, vedolizumab)

Medications used to decrease serum potassium?

Insulin, Sodium Bicarbonate (temporary treatment that shifts potassium into cells), Calcium Gluconate (temporary stabilizes myocardium preventing dysrhythmias), Dialysis (removes potassium from body), Sodium Polystyrene Sulfonate (removes potassium from body, don't give for a pt with a paralytic ileus as bowel necrosis can occur)

Decreased GFR

Kidney Disease Cirrhosis Shock Dehydration

GFR below 60 may indicate?

Kidney disease

MTX has elevation in what labs?

Liver enzymes or Serum Creatinine

Folic acid is given to pts with RA taking what to decrease drug side effects?

MTX (Methtrexate)

Nephrotic Syndrome key features

Massive proteinuria, hypoalbuminemia, edema (facial and periorbital), Lipiduria, hyperlipidemia, delayed clotting, increased bleeding, Increased (aPTT, INR, PT), reduced kidney function (elevated BUN, Creatinine, and decreased GFR

Uremia

Metallic taste in mouth, anorexia, n/v, cramps, uremic frost on skin, fatigue, lethargy, edema, dyspnea, paresthesia, hiccups

Hydroxychloroquine is generally tolerated well but in some cases pts report?

Mild stomach discomfort, light headedness, and headache

Which action would the nurse take when a client has returned from surgery with a nephrostomy tube?

Monitor site for leakage urine or blood, urine may be bloody 12-24 hours after procedure, 5 mL irrigation to check patency and dislodge clots, diuresis, I&Os, notify surgeon if hypotension, poor skin, dry mucous membranes, increased thirst, assess for infection, fever, urine characteristics

MTX side effects and toxic effects consists of?

Mouth sores, Acute dyspnea, pneumonitis, lymphoma

Methimazole teaching

Must be taken same time every day before food, notify if pregnancy occurs, Monitor pulse rate at home Avoid: calcium foods

Medications that are harmful to kidneys

NSAIDs, Iodinated Contrasts Medium, High osmo contrast, gadolinium enhanced MRI can result in (Nephrogenic Systemic Fibrosis), Gentamicin (AKI), oil, gas, mercury, lead, chlorine, drugs, laxatives, Herbs, analgesics, Tylenol, Creatine

Pts taking Sulfasalazine (Aminosalicylates) should be taught to report?

Nausea, vomiting, anorexia, rash, and headaches. High doses can cause hemolytic anemia, hepatitis, male infertility, agranulocytosis, assess for Sulfa allergy (Thiazide diuretics may be contraindicated)

Broad spectrum antibiotics

Neomycin Sulfate, Rifaximin, Azithromycin, Amoxicillin, Tetracycline, quinolones

Main form of AKI by NSAIDs is hemodynamically mediated the second form of NSAID induced AKI is acute interstitial nephritis which may manifests as?

Nephrotic Proteinuria

Biological Response Modifiers (BRMs) one of the newest classes of DMARD drugs act by

Neutralizing the biologic activity of tumor necrosis factor-alpha (TNFA) by inhibiting its binding to TNF receptors

How do you take a 24 hour urine?

On initiation of the collection, ask the patient to void, discard the urine, and note the time. If a Foley catheter is in use, empty the tubing and drainage bag at the start time and discard the urine. Collect all urine of the next 24 hr. Twenty-four hours after initiation, ask the patient to empty the bladder and add that urine to the container.

Radioactive iodine therapy (RAI) is not used in pregnant women because it can cross the placenta. The patient may receive RAI in what form

Oral form

Dialysis catheters have two lumens one for ___ and one for ___?

Outflow and inflow

The pt with hyperthyroidism should be taught to?

Perform deep breathing exercises, support the neck when coughing or moving by placing both hands behind the neck to reduce incision strain

The trauma team may use what diagnostics to assess for hemorrhage?

Peritoneal lavage, Ct, Ultrasound

Fluid challenges are often used to promote kidney perfusion. In pts without fluid overload 500-1,000 mL NS may be infused over 1 hour. It's important to assess for pt response to assess for?

Positive response or negative symptoms

A passive leg raise can determine if the pt is fluid responsive without the risk of giving fluids. Raise the pts leg to 45 degrees for 30-90 seconds to promote venous return. If SV or CO improve the pt will respond how to more fluids?

Positively

Patients with Oliguria usually have increased?

Potassium, BUN, restrict potassium and protein intake to prevent hyperkalemia and uremia from elevated BUN

Corticosteroid examples

Prednisone, methylprednisone, budesonide, hydrocortisone,

Methimazole can cause birth defects and should not be used during the first trimester of pregnancy. Instruct women to notify their primary health care provider if

Pregnancy occurs

Pts taking Leflunomide are recommended to use strict birth control and to contact the HCP immediately if

Pregnancy occurs while taking the drug

Antimicrobials

Prevent secondary infection, help pts with fistulas and anorectal abscess, monitor for upset GI, (Metronidazole, Ciprofloxacin, Clarithromycin)

Why are NSAIDs and ASA avoided for clients with kidney problems

Prostaglandins are inhibited by NSAIDs decreasing renal perfusion and can lead to AKI, long term use (CKD), GI perforation and ulceration, cirrhosis, thrombotic events,

Pts with AKI have a high rate of?

Protein breakdown, metabolism, catecholamines, cortisol, glucagon

ACEIs decrease loss of?

Protein in the urine

If GFR normal protein intake is needed if decreased GFR decrease

Protein intake

High dose prednisone for short durations or a chronic low dose is called?

Pulse therapy

Hydroxychloroquine has a serious side effect of?

Retinal damage, teach pts to report blurred vision and headaches

GN can lead to CKD it's essential to prevent and treat older adults for CKD due to increased risk. GN symptoms can easily be confused with symptoms of ___ sided heart failure?

Right

Assess for internal abdominal trauma by checking for blood in the urine and stool and by monitoring the abdomen for the development of

Rigidity and swelling

GN secondary diseases?

SLE, Hep B/C, Cirrhosis, Amyloidosis, MCGN, Alport syndrome, Vasculitis, IgA neuropathy, HIV, Diabetic Glomerulopathy

Hyperthyroidism ECG changes

SVT, A-Fib, PVCs

Weigh-bearing fracture of the pelvis such as the Acetabulum can necessitate external fixation or ORIF and can take how long before weight bearing?

Same day while some others will be managed with traction and can take as long as 12 weeks

Hydroxychloroquine is a DMARD (disease modifying antirheumatic drug) used for RA. It works by

Slowing the progression of mild RA before it worsens it's and antimalarial drug that suppressed the immune response to decrease joint and muscle pain

Kidney disease has increased Serum? Along with decreased Serum?

Sodium, potassium, phosphorous, and calcium

Managing infection as a cause of acute GN begins with appropriate antibiotic therapy. Penicillin, erythromycin, or azithromycin is prescribed for GN caused by

Streptococcal infection, check known allergies, stress, hygiene, complete entire course of antibiotics

Pregnancy is not recommended for pt's receiving MTX because birth defects are possible. For this reason we recommend

Strict birth control for childbearing women who are in need of MTX to control RA

immunosuppressive drugs

Suppress immune response, monitor CBC, suppression of the bone marrow may lead to inflammation in the pancreas and gallbladder, (Azathioprine, 6-mercaptopurine, methotrexate, cyclosporines)

Prior to starting BRMS administer a purified protein derivative (PPD) test for?

TB, BRMs can not be started until a negative PPD test is confirmed

Pts receiving BRMs have a high risk for developing impaired immunity and infection. Instruct pts to avoid crowds and remind patients with (MS, TB, or a past positive TB test) they can't receive?

TNF inhibitors such as BRMs because they make pts susceptible to flare ups of MS & TB

Preferred hyperthyroidism drugs are?

Thioamides (Methimazole, Propylthiouracil)

What does the nurse include when teaching safety measures to a patient with rheumatoid arthritis who is receiving methotrexate (MTX) therapy?

This is an immunosuppressive drug administered in a low dose once a week. It's slow acting and takes 4-6 weeks to begin controlling joint inflammation.

Don't palpate a goiter in a pt with hyperthyroid symptoms because this action can stimulate?

Thyroid storm (Release of excessive thyroid hormones)

GN has an onset of about 10 days from?

Time of infection

Fluid volume is calculated to be equal to?

Urine output plus 500 mL

The usual fluid allowance output is equal to?

Urine output plus 500-600 mL

Because the thyroid gland stores TH the pt may not have complete symptoms relief until 6-8 weeks after RAI therapy. Teach pts what precautions?

Use a private toilet for at least 2 weeks after RAI, sit to urinate, flush with the lid closed 3x after use, bag and seal toilet paper used to clean in sealable plastic bags and take to hospital radiation department, laxative usage on second and third day, wash clothes separate from others, run cycle empty after use, 3 ft away from pregnant women, infants and young children, don't share hygiene items

Cholesterol lowering drugs (satins) can improve blood lipid levels and Heparin may reduce?

Vascular defect and improve kidney function

Which assessment data would be a major concern for the nurse when caring for a patient admitted to the emergency department with pelvic fractures?

Vital signs, skin color, LOC

Long term dialysis catheter may be placed by radiology using tunneling under moderate sedation under ultrasound or fluoroscopic guidance. The physician makes an incision where the jv passes the clavicle. A 6-8cm tunnel is created

away from the site incision

renal vein thrombosis

blood clot in the renal vein

Increased GFR

causes increased urine output, which lowers blood pressure, and vice versa

If infiltration of a solution containing potassium occurs, stop the IV solution immediately, remove the venous access, and notify the health care provider or Rapid Response Team. Document these actions and provide a

complete description and photograph of the IV site.

Abatacept is a selective T-lymphocyte inhibitor report signs and symptoms of

cough, dizziness, sore throat, no live vaccines, dyspnea, wheezing, flushing, itching

Vascular access for KRT in pts with AKI is made by catheter specific placement for

dialysis in a central vein most often the internal jugular vein.

For patients with exophthalmos, prevent eye dryness by

encouraging the use of artificial tears.

impotence

erectile dysfunction

IV fat emulsion (Intralipid) infusions can provide a nonprotein source of calories. In uremic patients, fat emulsions are used in place of glucose to avoid the problems of

excessive sugars.

End-stage kidney disease

fatigue, decreased alertness, anemia, decreased urination, headache, and weight loss. (GFR) is less than 15 mL/min, Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are also high in calcium.

Pts with NS have high serum lipid levels and display with?

fats in the urine, edema, HTN

Nephrotic Syndromes (NS) main feature is

increased protein elimination with severe proteinuria (more than 3.5g in 24hrs).

Ask pts with hyperthyroidism about sensitivity to

light (photophobia)

Hypothyroidism crisis

myxedema coma

The 3 Albuminuria stages considered in CKD are defined by the albumin-to-creatinine ratio in urine. Stage 1 is? Stage 2 is? Lastly Stage 3 is?

none to mildly increased albumin up to 29 mg/g creatinine and is sometimes called microalbuminuria. • The second (A2) stage has values of 30 to 300 mg/g creatinine • The stage of greatest kidney damage (A3) has values >300 mg/g creatinine risk for KD increases when urine albumin increases

ORIF

open reduction internal fixation

dysuria, oliguria

painful urination, decreased urine output (scanty)

Report pts with hyperthyroidism to report

palpitations, dyspnea, vertigo, chest pain, temperature increase, fever, HTN

The Joint Commission's National Patient Safety Goals mandate that concentrated potassium be diluted and added to IV solutions only in the

pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in patient care areas.

Apoptosis

programmed cell death

ESKD is fatal without?

renal replacement therapy (dialysis) or a transplant

Kidney replacement therapy (KRT) indicated for?

symptomatic uremia, pericarditis, neuropathy, decline in cognition, persistent or rapidly rising high potassium levels (greater than 6.5), severe metabolic acidosis (pH <7.1), fluid overload, drug or alcohol intoxication

uremia, azotemia

urine in the blood, excessive) urea and nitrogenous substances in the blood

Propylthiouracil, methimazole

used in hyperthyroidism. blocks peroxidase, thereby inhibiting organification of iodide and coupling of thyroid hormone synthesis. PTU also blocks - 5 deiodinase, which decreased peripheral conversion of T4 to T3. Toxicity includes: skin rach, agranulocytosis (rare), aplastic anemia, hepatotoxicity (PTU). Methimazole is a possible teratogen.

Hypothyroidism S/S

weakness, anorexia, muscle aches, paresthesia, cold intolerance, constipation, decreased libido, amenorrhea, impotence, infertility dyspnea, hypoventilation, bradycardia, hypotension, dysrhythmias, weight gain, pleural effusion, abdominal distention,