NUR 325- Exam 3

What are the downsides to cultured epithelial autograft?

- ~$4,000 for each small square (expensive) -Biopsy and then ready 4-6 weeks (takes awhile) -Can slough off easy

What in included in patient education about preventing hypo/hyperglycemic events?

-*Maintain adequate hydration -Consume liquids with CHO and electrolytes (sports drinks) when unable to eat solid food -*Monitor glucose Q1-4 when ill and continue to take insulin -Notify PCP when an illness persists for greater than 1 day -*Encourage pt to obtain and wear medic alert bracelets -*Educate family that changes in LOC may indicate the need for medical attention * = especially for older adults

What type of IV fluid would you give a patient with DI if they are hypernatremic?

-.9% normal saline -.45% NaCl because they have less Na than other fluids and will not worsen the hypernatremia

What is the incidence like for burns?

-1.1 million in the US every year -Commonly from booking, bathing, and appliances -Elderly and young children most at risk

How do you estimate serum osmolality?

-2 x Serum Na (normal Na is around 140, 140x2 = 280, and extra stuff like glucose and BUN is included)

What is blood flow to the liver like?

-20% comes from hepatic artery -80% comes from portal vein (veins around small intestinal tract, gives all molecules to portal veins from small intestine)

What are examples of 15g of fast acting carbohydrates that you would give to a hypoglycemic patient?

-4 glucose tablets -1/2-1 tube of glucose gel -4 ounces of fruit juice -1 tbsp of corn syrup -8 ounces of milk -1 tbsp of jam, preserves, jelly, honey, or sugar

What is the general nursing management like for burns?

-ABC's -FLUID -Cool minor burns to halt burn process or for intermittent pain relieve, but never use ice since it causes massive vasoconstriction leading to blood flow/circulation problems -When more than 1/3 of TBSA is burned, the body will activate SIRS (whole body inflammation)

What medications can cause SIADH?

-ACE inhibitors -Amiodarone -Narcotics

When is continuous renal replacement therapy (CRRT) prescribed?

-ARF/FVE -SICK patients -ICU only

What are the implications for rhabdomyolysis?

-ATN causing AKI -Metabolic acidosis -Tea colored urine -Coca-cola colored urine -Tea and coca-cola colored urine are from myoglobin

What happens during acute renal failure?

-Abrupt loss of renal function with increased serum creatinine and decreased GFR

What are the top causes of failure in chronic kidney disease?

-Acute renal failure -Diabetes mellitus -HTN, especially among African Americans -Polycystic kidneys disease -Infection (acute progressing to chronic glomerulonephritis, pyelonephritis) -Nephrotoxic meds -SLE (lupus) -Rhabdomyolysis

What is the leading cause of mortality among hospitalized pts?

-Acute renal failure. -50% of pts have iatrogenic cause (we gave it to them in the hospital from things like not effectively monitoring urine output)

What is ATN?

-Acute tubular necrosis -Damage to the kidney tubules -Most common type of intrinsic AKI -Characterized by intratubular obstruction, abnormal reabsorption of filtrate and decreased urine flow through tubule, vasoconstriction, and changes in glomerular permeability → decrease of GFR, progressive azotemia, and fluid & electrolyte imbalances -Caued by CKD, diabetes, HF, HTN, and cirrhosis

What are the disorders/imbalances of adrenal hormones?

-Addison's Disease -Cushing Syndrome

What is the incidence of cirrhosis like?

-Affects men 2x more than women -Peaks between 40 and 60 years old, can be caused from alcoholism in teenaged years carried on into adulthood -12th leading cause of death in the US among young and middle-aged

What are the nursing diagnoses for burns?

-Airway -Gas exchange -Perfusion -Fluid volume -Rish for infection -Pain

What are the hepatic diagnostics for protein sythesis?

-Albumin -Prothrombin time (PT)

What hepatic diagnostics determine biliary duct integrity?

-Alkaline phosphatase (ALP or Alk Phos) -Bilirubin

What types of shock will a patient have flushed skin?

-Anaphylactic shock -Septic shock

What are the hematologic manifestations of chronic kidney disease?

-Anemia -Bruising -Bleeding from decreased erythropoietin

What are the early (compensated) manifestations of cirrhosis?

-Anorexia -Nausea -Vomiting -Chronic dyspepsia -Fatigue -Enlarged, firm liver -RUQ heaviness -Palmar erythema -Spider angiomas -Epistaxis -Pedal edema -Mild fever Not very specific

What are the 2 parts of the pituitary gland?

-Anterior -Posterior

What would you use to decrease HR in cardiogenic shock?

-Anti-dysrhythmics -Pacemaker

What are the medications given to kidney failure patient?

-Antihypertensives (ACE, ARB, Ca Channel Blocker) -Iron supplements, folic acid, Nephrovite, MVI -Sodium polystyrene -D50 and insulin -IV Ca gluconate -Erthropoietin alfa -Alkalizers (sodium bicarbonate) -Phosphate binders (calcium acetate/PhosLo and aluminum hydroxide/Nephrox) -Calcium supplements (calcium w/ active vitamin D like calitrol/Rocatrol) -Stool softeners (docusate sodium/Colace, sorbital, biscodyl/Dulcalox) -Diuretics

What are the types of access for hemodialysis?

-Arteriovenous Fistula (AV fistula) -Arteriovenous graft (AV graft) -Temporary vascular access

What are the hepatic diagnostics that determine hepatocyte integrity (basics of liver cell function)?

-Aspartate transaminase (AST): non-specific -Alanine transaminase (ALT): most specific

How do you assess if the hemodialysis access is working?

-Assess for thrill: will feel turbulent blood flow -Assess for bruit: hear swishing of turbulent blood flow with bell of stethoscope -Don't access unless you have the thrill or bruit

What are the key characteristics of renal angiogram?

-Assesses blood flow -Catheter inserted into the artery and threaded through until it is placed in the renal (kidney) artery, and then contrast medium is injected into the artery -Visualize arterial tree, capillaries, and venous drainage of kidneys to obtain data on the presence of tumors, cysts, stenosis infarction, aneurysms, hematomas, lacerations, and abscesses

What are the neuro symptoms of hepatic encephalopathy?

-Asterix (push hand back and get jerky hand moement) -Constructional apraxia ( unable to construct/draw lines on star) -Disorientation/confusion -Change in LOC -Fetor hepaticus -Hepatic coma

What are the modes of peritoneal dialysis?

-At home -Octopus (cycler)

What medications are used to increase HR in shock patients?

-Atropine -Epinephrine

How do ligating bands help esophageal varices?

-Attack bleeding spot by itself -Endoscopy/videoscope finds area of bleeding, irrigate and suction, and put rubber band around and tighten so they can't bleed

What are the types of grafts?

-Autograft -Homograft -Heterograft

What is Steven's Johnson Syndrome?

-Autoimmune syndrome that happens usually due to medication or disease -Unpredictable due to medication or disease -Treat like a burn -Basically full body superficial partial thickness burn -Skin starts to slough off -Reverse isolation, fluid loss risk, and infection risk

What are the indications for dialysis?

-BUN >90 mg/dl -Serum creatinine >9 mg/dl -Hyperkalemia -Drug toxicity -FVE -Metabolic acidosis -Uremia (pericarditis, GI bleeding) -Mental changes

How is renal transplant done?

-Bad kidney not usually removed -More of a risk to get rid of bad kidney than it is to put in a new one since you have to cut a lot more when taking one out

What are some of the invasive interventions for esophageal varices?

-Balloon tamponade -Sclerotherapy -Ligating bands -Transjugular intrahepatic portosystemic shunt (TIPS)

What happens when baroreceptors and chemoreceptors activates the Autonomic Nervous System?

-Baroreceptors and chemoreceptors sense decreased body stroke volume → -Increase in epinephrine and norepinephrine → -Increase HR -Vasoconstriction → shunting of blood to center organs

What starts and ends the initiation phase of acute renal failure?

-Begins with insult (ex: surgery, admission to hospital) -End with oliguria

How does chronic kidney disease begin and progress?

-Begins with reduced renal reserve, then progresses through stages/phases -Progressive and irreversible

What is a paracentesis?

-Beside or outpatient removal of fluid from the peritoneal cavity (ascites) -Not a fix for cirrhosis or portal HTN, just prevents uncomfortable consequences of ascites

What is indirect (unconjugated, lipid soluble) bilirubin?

-Bilirubin resulting from spleen breakdown of RBCs -Bound to albumin

What is the appearance like for deep full thickness burns?

-Black -No edema

What are the manifestations of DIC?

-Bleeding from everywhere -Symptoms related to blood loss -Symptoms related to microvascular thrombosis ^decreased LOC ^angina ^hypoxemia (tissue perfusion problems everywhere) ^oliguria (kidneys clogged) ^peripheral cyanosis (purpura and petechiae) -Little clots are like little strokes, so it causes neuro problems

What is a serious complication of esophageal varices?

-Bleeding! Remember they have inadequate clotting factors, so even small bleeds take long to stop -20% mortality with 1st bleed

Why do we give ACE inhibitors?

-Blocks angiotensin-converting enzyme which is a part of RAAS. -Give ARB or Ca channel blockers if pt cannot tolerate ACE inhibitors

What happens during hemodialysis?

-Blood is diverted from the pt into a dialyzer, a synthetic permeable membrane which filters blood at a rate of 300-400 ml/hr -200 cc of blood in machine at one time -Tubing flushed with normal saline and heparin, blood flows through tubes in coil, and bath on outside of tubing never mixes -Wastes and fluid removed -Usually done 3x a week for 3-4 hrs each time

What is BUN?

-Blood urea nitrogen -Waste product of protein metabolism

What is type 2 diabetes?

-Body becomes resistant to insulin -Impaired secretion of insulin -Most common in obese population

What can increasing the Na by more than 12 meq in 24 hours cause?

-Brain damage -Death

What are examples of a full thickness burn?

-Burn scalds -Grease burn -Tar burn -Chemical burn -Electrical burn -Prolonged exposure to hot objects

What pre-existing conditions should nurses be alert to when older adults are hospitilized with HHS?

-CHF -Renal compromise -Pulmonary problems -Certain age-related changes because these make the patient more prone to fluid overload

What is ionized calcium and when is is drawn?

-Calcium available for the body to use -Extra lab draw done in pt with low protein levels to see how much calcium they have available in their body to use

What is important to note about inhalation injuries?

-Can be seen in nares -Worry about airway problems from smoke and lack of oxygen, burnt mucous membranes, and swelling -Inbutation is a priority -Styrafoam around ET tube since there is nothing safe to tape it to

What are key characteristics of renal ultrasound?

-Can detect kidney stones -Make sure they have a full bladder for this -Images the ureters, bladder, masses, cysts, calculi, and obstructions of lower urinary tract. -Helpful in evaluating for obstruction and differentiating acute and chronic renal conditions. (kidneys often small in chronic)

What causes filtration to occur?

-Capillary hydrostatic pressure is increased → filtration -Glomerular filtration occurs as the result of a pressure gradient, which is the difference between the forces that favor filtration and the pressures that oppose filtration

What are the problems of the different body systems from burns?

-Cardiovascular system: cardac depression, edema, hypovolemia -Pulmonary: vasoconstriction, edema -GI: impaired motility and aborption, vasoconstriction, loss of mucousal barrier function with bacterial translocation, increased pH -Kidney: vasoconstriction -Other: altered thermoregulation, immunodepression, hypermetabolism

What are the components of peritoneal dialysis?

-Catheter -Solution

What are the causes of SIADH?

-Central nervous system disorders: ^head injury ^infection ^surgery ^stroke -Ectopic production of ADH from malignant disease (small cell carcinoma of lung) -Medications

What are the clinical manfestations of Cushing's syndrome?

-Central-type obesity -Buffalo hump in neck -Moon face -Thin extremities -Retention of Na and water -Hyperglycemia and/or DM -Excessive growth of facial hair in women -Depression

What are the causes of DI?

-Central: primary injury to the posterior pituitary or hypothalamus (head injury or surgery) -Nephrogenic: failure of the renal tubules to respond to ADH

What is the pathophysiology of portal hypertension?

-Chaotic structure in liver blocks normal inflow via portal vein (hepatic artery remains intract -High back pressures in portal venous system → edema, ascites, retention of aldosterone, esophageal varices → can back up into pancreas and spleen

What are the key characteristics of a renal scan?

-Checking for things that need radioactive dye -No pregnant nurses -Pt will be radioactive for 24 hours (including urine- flush twice) -Assesses renal blood flow and estimates glomerular filtration rate after IV injection of radioactive material to produce a scanned image of the kidneys

What happens during the recovery phase of ARF?

-Chemistries return to previous levels -May have permanent 1-3% GFR reduction -Signals the improvement of renal function

What is cirrhosis?

-Chronic progressive disease characterized by: Degeneration →Destruction →Fibrosis →Ultimately necrosis of the liver

What is the care like for superficial partial-thickness burns?

-Clean with soap/water -Topical Bacitracin -Large areas/dressings -Daily dressing changes

What is shock?

-Clinical syndrome of inadequate tissue perfusion -Body's perfusion is unable to meet the metabolic demands of the tissues (imbalance of O2 supply and demand)

What stages of shock will a patient need a central or arterial line?

-Compensatory -Refractory

What is burn rehabilitation like?

-Complex, comprehensive and very long process -Emotional (>45% with PTSD) -Burn wound in dynamic state for greater than 1 year -Up to 23% DVT rate -Family stress due to financial and locations of burn centers

What are the characteristics of the solution in peritoneal dialysis?

-Composition determined by patient need (1.5%, 2.5%, 4.25% dextrose) -2 liter bags -Warmed to promote vessel dilation, increase pt comfort, and prevent hypothermia and vasoconstriction

What is uremia?

-Condition from increased uric acid -Sxs are manifestations of azotemia (fatigue, lethargy, headache, confusion, malaise, muscle cramps, anorexia, nausea, vomiting, pruritis)

What are the different type of fluid formulas and what is different between them?

-Consensus, Evans, ABA, Brooke Army, Parkland/Baxter -Differ between what ml amount to multiply by

What are important nursing implications for percutaneous liver biopsy?

-Consent/labs needed -Want to stick needle in while they are expiring so diaphragm is up and out of the way -Maintain pt on affected side after biopsy (RIGHT SIDE)

What is peritoneal dialysis like at home?

-Continous or intermittent -Various amount of exchanges (4-5 per day or night)

What is the nursing care that is done specifically for chronic kidney disease patients?

-Control dietary protein based on pt's stage of renal disease (may need protein added due to breakdown, but dont want too much bc then kidneys have to filter more) -Limit Na, K, phosphate, and Magnesium bc it worsens the disease -Refer to community resources -Encourage compliance with diabetic regimen -Encourage pneumococcal vaccine and yearly influenza vaccine -Teach pt to measure liquids, weight, and BP at home -Teach pt sxs that require immediate attention

What is the specific treatment like for cardiogenic shock?

-Coronary angiogram -Optimizing preload and afterload -Vasoactive medications (norepinephrine, epinephrine, nitroglycerin, dobutamine, amoidarone, beta blockers)

What is correction of electrolyte imabalances like for DKA?

-Correct deficits of Na, Cl, HCO3, PO4, K, and Mg -Must prevent hypokalemia as K shifts into the cells with glucose and insulin -May require K replacement, frequent K levels, and EKGs

What are the hormones produced by the adrenal cortex?

-Cortisol -Aldosterone -Sex hormones (androgens)

What are the nitrogenous waste urine lab diagnostics?

-Creatinine Clearance (24 hr) -Protein

What is the area involved in full thickness burns?

-Damage to the entire epidermis and dermis -May extend to subcutaneous tissue -Nerve damage occurs

What are the clinical manifestations of Addison's disease?

-Dark pigmentation of skin -Low blood glucose -Low Na -Hypotension -High K -Depression -Early morning serum cortisol decreased and increase in plasma ACTH

How is the 24 hour creatinine clearance collection done when a patient is voiding?

-Day one: discard first urine, then collect -Day two: first urine into container, then the 24 hours are done -Draw serum creatinine at the end of the 24 hours for comparison

What is the care like for full-thickness burns?

-Debride -Silver? -Dressings (inital and secondary) -Re-debride -Skin graft -Graft care -Bear hugger because of temperature issues

What is the care like for deep partial-thickness burns?

-Debride bc the tissue won't heal -Silver Nitrate (silver sulfadiazine), hydrogels -Keep covered, moist dressings -Temporary skin substitute (like vaseline gauze) -More dressing care

What are the signs and symptoms of the progressive stage?

-Decreased BP -Further increased HR -Rapid shallow respirations -Mottled skin -Further reduced urine output -Lethargy -Metabolic acidosis

How does the endocrine system contribute to the regulation of BP?

-Decreased CO → -RAAS activation → -Increased ADH (retains water, vasoconstriction) -Aldosterone (retains sodium and water) → -Decreased UOP -Systems being stimulated → -Increased metabolic demand → -Glycogenolysis/gluconeogenesis → -Carb, protein, and fat breakdown → -Increased blood sugar

What causes shock?

-Decreased cardiac function -Low intravascular fluid volume state -Decreased vascular tone

What is GRF like in chronic kidney disease?

-Decreased. -We can see this with a lower urine output and 24 hour creatinine clearance

What are the factors that affect BUN?

-Dehydration -Infection -Chemotherapy -Steroid therapy -Reabsorption of blood in the liver from damaged tissue

What does protein intake for cirrhosis patients depend on?

-Depends on level of cirrhosis -The worse the cirrhosis, the less they can do anything with protein intake -Early on you encourage protein intake, later on you limit

How is a low-dose dexamethason (decadron) suppression test done and what is normal?

-Dexamethason given before bed and a plasma cortisol level is obtained at 8am the next morning -Normal: cortisol level less than 5 mg/dl

What are the main disorders of the pituitary gland?

-Diabetes Insipidus (DI) -Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

What is the nurses role in care for MODS?

-Diagnosis of each system -Management based on shock managment but for multiple systems -Goal: prevent the progression of SIRS to MODS -Vigilant head to toe assess,ent -Ongoing monitoring to detect early signs of deterioration or organ dysfunction are critical

What are the pre-op nursing actions for a pt receiving a renal transplant?

-Dialysis day before or day of surgery -Labs: CBC, PT, electorlytes, creatinine, bilirubin, T&C, blood type (ABO) compatibility, human leukocytic antigen (HLA), and other minor antigen -Dx tests: CXR, EKG, Pap, dentist (want to make sure no infections!) -Compliance is crucial -Medication: antibiotics, heparin, steroids (Solumedrol), and immunosuppressants

What is the treatment like for hyperglycemia?

-Diet control -Insulin therapy

What is anion gap and what is the normal range?

-Difference or gap between the negatively charged and positively charged electrolytes -Normal: 8-16 meq/L

What is DIC?

-Disseminated intravascular coagulation -Widespread intravascular fibrin formation and clotting cascade activation -Uncontrollable clotting in small blood vessels -Causing body to break down clots -All clotting ability is used up -Bleeding and clotting at the same time -Body coagulation factors become hyperactive and are readily depleted

What is used to increase contractility in shock patients?

-Dobutamine -Dopamine

Why are electrical burns especially danverous?

-Doesn't look so bad, but everything in the path is burned -Not a lot of people survive from bad electrical burns

What are the key characteristics of a renal biopsy?

-Done percutaneously -Check pt coags -Hold pressure -It is s tissue sample of kidney to tell how well the kidney is functioning -Seen more in transplants -Needle in back gets us tissue sample -Need consent for this -Lay them on their back to hold pressure on kidney after biopsy

What are the key characteristics of heterograft/xenografts?

-Donor from animals (usually pig) -Same care of allograft

What are the key characteristics of homograft/allografts?

-Donor from cadaver or other living human -Generally rejected by host body so used only temporarily -Protection against fluid loss and infection -It eventually will come off

What are the respiratory manifestations of chronic kidney disease?

-Dyspnea -Tachypnea (compensation) -Pleuritis -Crackles -Kussmaul's respirations -Hiccups -Pulmonary edema

What is the difference in temp between early and late septic shock?

-Early = warm -Late = cold

What decreases mortality in septic shock?

-Early cultures -Early antibiotic admin

What is nutrition management like in shock patients?

-Early feeding is recommended -Enteral (tube through gut) is preffered -Parenteral (TPN) through vein/central line is another option

What is uric acid like in chronic kidney disease?

-Elevated -Could possibly be normal -Usually already on dialysis at this point

What are the signs of renal transplant rejection?

-Elevated temp -Decreased or sharply increased urine output -Pain/swelling over graft site -Elevated BP -Increased weight (>2 lb/day or 5lb/week) -Elevated BUN/creatinine this can be acute or chronic failure

What are the priorities during the emergent/resuscitative, acute/intermediate, and rehabilitation phases of burn treatment?

-Emergent/resuscitative: Airway, Breathing, Circulation, Disability including neuro deficit, Expose and examine while maintaining a warm environment, prevention of shock, prevention of resp distress, detection and tx of concomitant injuries, wound assessment and initial care -Acute/intermediate: wound care and closure, prevention or tx of complications like infection, and nutritional support -Rehabilitation: prevent and tx of scars and contractures, physical, occupational, and vocational rehab, functional and cosmetic reconstruction, and psychosocial counseling

What are the diagnostic findings that indicate hyperthyroidism?

-Enlarged thyroid gland that might pulsate, have palpable thrill, and/or an audible bruit -Decreased TSH -Increased T3 -Increased T4

What are the hormones produced by the adrenal medulla?

-Epinephrine -Norepinephrine

What are the causes of Cushing's syndrome?

-Excessive corticosteroid -Tumor of the pituitary gland (causing excess ACTH production) -Bronchogenic carcinoma (causing excess ACTH production) -(Rarely) hyperplasia of adrenal cortex

What are general manifestations of chronic kidney failure?

-Fatigue -Lethargy -Depression these can lead to medication noncompliance because they don't want to be messed with

What is the purpose of the luteinizing hormone?

-Female: production of estrogen and progesterone -Male: stimulates testosterone

What is the purpose of the FSH?

-Female: stimulates growth of ovarian follicle -Male: stimulates sperm production

What are the main characteristics of the initiation phase of shock?

-First stage -Caused by decreased myocardial contractility, intravascular fluid volume depletion, and/or decreased vascular tone -Results in decreased perfusion -No signs or symptoms -Body can compensate -May have decreased stroke volume or cardiac output (but isn't likely you'd be monitoring them)

What is included in the nursing management for burns?

-First: fluid resuscitation -Prevent infection/isolation (reverse isolation) -Nutrition (high calories and protein): tPN is common -Dressings -Grafts -Pain management (opioids) -Warm room (bc pt can't maintain own body temp) -Vitals -I/O and urine quality (myoglobinuria)

What are examples of a superficial partial thickness burn?

-Flame -Burn scalds

What are examples of a deep partial thickness burn?

-Flame -Burn scalds -Grease burn -Tar burn -Chemical burn -Prolonged exposure to hot objects

What are some types of burns from most common to least common?

-Flame related -Scalds -Direct source contact -Electrical -Chemical -Misc/unidentified -Inhalation

What happens during outflow in peritoneal dialysis?

-Fluid drained by gravity to designated collection bag -Should have more out than in -Unclamp outflow bag and let it drain like foley -Should have more out than in

What is the treatment for DKA?

-Fluid resuscitation -Electrolyte management (especially K) -Correcting hyperglycemia and acidosis (insulin and bicarb administration) -Respiratory support

What is the treatment like for HHS?

-Fluid resuscitation (.9% NaCl or .45% NaCl) -Electrolyte management (especially K) -Correcting hyperglycemia (IV insulin and then SQ)

What are the nursing implications for IV insulin?

-Flush IV tubing with 50 mls and let it sit for 30 minutes because insulin binds to the IV tubing, so if you start it right away the patient won't receive the appropriate amount of insulin. -ONLY CAN USE REGULAR INSULIN IV

What are the hormones produced by the posterior pituitary?

-Follicle Stimulating Hormone (FSH) -Luteinizing hormone (Lh) -Prolactin -Anti-diuretic hormone (ADH) -Oxytocin

When are the purpose of grafts?

-For feep partial thickness or full thickness -Decreases risk for infection -Prevents further loss of fluid and protein -Minimized heat loss -Permits earlier functional ability and less contractures

Why do we monitor for infectionin edema/ascites?

-From stagnant fluid -Sxs will be abdominal pain, redness, fever, etc

What are the signs and symptoms of the refractory stage of shock?

-Further reduction in BP -Erratic HR -Pt is no longer able to support their respiratory status -Jaundice -Anuric -Unresponsive -Mixed respiratory and metabolic acidosis

What is normal urine output?

-Generally: 1-2 L/day -0.5-1 ml/kg/hr -People greater than 150 lb will need a lot more fluid

What does glucose depend on in cirrhosis and why?

-Glucose depends on diet and level of liver failure -Liver can't breakdown glycogen stores to maintain glucose level

What are the functions of the liver?

-Glucose metabolism -Ammonia conversion -Protein metabolism -Fat metabolism -Vitamin and iron storage -Bile formation -Bilirubin excretion -Drug metabolism

What are the causes of hyperthyroidism?

-Graves disease (most common) -Toxic adenoma -Toxic multinodular goiter

Why are patients with cirrhosis encouraged bedrest?

-Gravity -Liver is heavy, so standing puts more pressure on liver -Maintaining flat helps take stress off liver and allows more blood flow -Worries about falls, bleeding, edema, and jaundice in skin causing breakdown

What are the hormones produced by the anterior pituitary?

-Growth hormone (Gh) -Adrenocorticotropic hormone (ACTH) -Thyroid Stimulating Hormone (TSH)

What does high BUN/Cr ratio indicate?

-HF -Dehydration

What are the cardiovascular manifestations of chronic kidney disease?

-HTN -Edema -Pericardial effusion -CHF (prolonged) -CAD -Rhythm abnormalities (prolonged)

What is the process like of an autograft?

-Harvest sites from anywhere into dermal layer -These areas taken from can be more painful than the burn area -Can be from butt, thigh, upper arms, scalp, back, or abdomen

What is the rule of 9's?

-Head and neck - 9% (4.5% for front + 4.5% for back) -Each arm - 9% (4.5% for front + 4.5 for back) -Upper chest - 9% -Upper back - 9% -Abdomen - 9% -Lower back - 9% -Each leg - 18% (9% for front + 9% for back) -Perineum - 1%

What is the sensation/healing like for deep full thickness burns?

-Heals within weeks to months -Scarring -Grafting required -May require amputation

What are the manifestations of an esophageal varices bleed?

-Hematemesis -Melena -Low BP -High HR

What are the key characteristics of AV fistula?

-Hemodialysis access of choice! -Hole between 2 parts -Try to start as distal as possible -Surgery to suture artery and vein together so they can use the big hole to put needle in -Vein might look like it's "popping out" of skin -Takes 4-6 weeks to mature

What are the types of jaundice?

-Hemolytic (increased RBC breakdown) -Obstructive (biliary backup) -Hepatocellular (clogged liver)

What does the liver lobule consist of?

-Hepatocytes -Sinusoids -Bile canaliculi

What is the treatment like of hypothyroidism?

-Hormone replacement -Fluid resuscitation (.9% NaCl) -Electrolyte replacement -Supportive care (passively rewarm and intubate if needed)

What are the clinical manifestations of hypoglycemia?

-Hunger -Sweating -Tremors -Nervousness -Confusion -Grumpy -Somnolent/sleepy -Headache -Slurred speech -Impaired coordination

What factors are included in recipient selection of kidney transplantation?

-Hx of compliance -Absence of infection -Blood type (ABO) compatability -Histocompatability -Donors can be living, cadaver, related, or not related

What can imbalances of insulin lead to?

-Hyperglycemia -Hypohlycemia -Diabetes -Diabetic ketoacidosis -Hyperosmotic hyperglycemia

What is hypoglycemia? Severe hypoglycemia?

-Hypoglycemia: glucose levels of <70 mg/dl -Severe: glucose levels of <40 mg/dl

What are the signs and symptoms of anaphylactic shock?

-Hypotension -Laryngeal edema -Bronchoconstriction -Nausea/vomiting -Cardiac arrest

What are the complications that we should monitor for during hemodialysis?

-Hypotension due to rapid fluid removal -Clotting/bleeding -Loss of access -Disequillibrium syndrome -Dysrhythmias due to F&E shifts -Air embolism

What are the disorders of the thyroid gland?

-Hypothyroidism ^Myxedema coma -Hyperthyroidism

What are the types of shock?

-Hypovolemic (volume) -Cardiogenic (pump) -Obstructive (block) -Distributive (tone) ^Anaphylactic ^Neurogenic ^Septic

How do you prevent causative factors?

-I&Os -Daily weights -Peak and trough level monitoring to make sure drug level not toxic

What is the treatment like for shock?

-ID and correct the cause (always a fluid balance problem) -IV access -Fluid replacement -Vasoactive medications -Glucose control -Electrolyte replacement -End organ support -ABCs!

What is the nursing care that is done specifically for acute renal failure patients?

-Identify and correct the underlying cause -Prevent prolonged hypotension or hypovolemia -Prepare for possible fluid challenge and diuretics -Restrict fluid during oliguric phase depending on how damaged the kidneys are -Restrict dietary intake of sodium and potassium during the oliguric phase (make sure it is kept consistent) -Monitor protein since protein wastes are accumulated in blood

What are the complications to monitor for after hemodialysis?

-If temperature >99.6 suspect sepsis and anticipate blood cultures -Dysrhythmias -Hypovolemia -Bleeding at access site -Disequilibrium syndrome (serios!) -Hepatitis and other blood-borne pathogens -Anemia secondary to end-stage renal disease and hemodialysis

What are the results of cirrhosis?

-Inability to filter out bilirubin -Resistance to blood flow leading to portal hypertension -Alteration in nutrient metabolism (glucose, proteins, and fats) -Decreased ability to deaminize proteins and to inactivate drugs/toxins

What is used to optimize preload in shock patients?

-Increase: IV fluids -Decrease (in cardiogenic): diuretics or vasodilators

What are the signs and symptoms of the compensatory stage of shock?

-Increased HR -Increased RR -Cold and clammy skin -Reduced urine output -Confusion or agitation -Respiratory alkalosis

What is the same between all the different types of shock?

-Increased HR -Increased RR -Decreased BP -Decreased UOP -Decreased CO -Decreased LOC -Decreased perfusion -Resp alkalosis progressing to metabolic acidosis

What are the causes of metabolic acidosis?

-Increased serum potassium -Decreased elimination of H+ ions -Inability to conserve bicarbonate (HCO3)

What does total bilirubin consist of?

-Indirect bilirubin -Direct bilirubin

What are the cycles of peritoneal dialysis?

-Inflow -Dwell time -Outflow

When are isotonic crystalloids given in shock?

-Initial fluid resuscitation -Maintenance -Challenge

What are the phases of shock?

-Initiation (almost invisible) -Compensatory (by body system) -Progressive (when body stops being able to compensate) -Refractory (close to death)

What are other medications used in shock management?

-Insulin -Steroids (controversial) -Antibiotics (priority in septic shock!!) -Nutrition -Anticoagulants (to prevent problems) -Proton pump inhibitor

How do we give D50 and insulin to chronic kidney failure patients and why?

-Insulin (10 units IV) to pull K into cell -D50/dextrose (1 amp) to keep pt from being hypoglycemic

How does insulin lower potassium?

-Insulin carries dextrose into cells → takes potassium straight into cells and out of serum -Need to be given glucose with it because it also pulls that available dextrose into the cells with it and you want to prevent hypoglycemia

How is continuous renal replacement therapy done?

-Internal jugular vein or femoral -Slow, continuous removal of fluid and solutes (up to 40 days) -Many different forms -Hemodialysis nurse sets it up -Bedside nurse responsible for maintaining by keeping lines connected and looking at output

What is included in the shock management of airway and oxygenation?

-Intubate early -Monitor tidal volume and PEEP for CO2 management and oxygen recruitment (complicated management) -Opioids (fentanyl) -Sedation (midazolam) -Paralytics/Neuromuscular blocking (succinylcholine, vecuronium or rocuronium)

What is the pharmacological therapy like for treating hyperthyroidism?

-Irradiation to destroy the effects of the thyroid gland -Antithyroid medications to inhibit one or more stages of hormone synthesis or hormone release

What IV fluids are given in shock?

-Isotonic crystalloid (normal saline and lactated ringers) -Colloids (albumin) -Blood (PRBCs)

What is the treatment like for DIC?

-Isotonic fluids and colloids to keep fluid in circulatory system -Blood products -Heparin/lovenox to block the clotting process all over again -Fibrinolytics (LAST LINE!!) -Stop bleeding (OR, IR, cauterizing)

Why is noncompliance seen with sodium polysterene?

-It causes loose stools -Tastes bad

What are the late (decompensated) manifestations of cirrhosis?

-Jaundice (biliary obstruction) -Edema (low albumin) -Bleeding (high PT due to low clotting factors) -Portal HTN leading to: ^ascites ^esophageal varices -Spontaneous peritonitis and infection -Vitamin deficiencies (A, C, and K) -Anemia -Hepatic encephalopathy -Hepatorenal failure (very bad)

What are the medical imaging used in kidney diagnostics?

-KUB (x ray) -Renal ultrasound -Renal scan -Renal biopsy -Renal angiogram

What are some steps to take to prevent burns?

-Keep water heater temp at maximum 120 degrees -Put smoke alarms on every level of home

What would be seen in abnormal filtration?

-Kidney disease -Bowman's capsule may be broken and there is more UOP -Bowman's capsule may be really broken and there is no UOP -BP can be too high and mess with blood flow to kidneys, causing less UOP

What increases serum creatinine?

-Kidney disease is the only condition that increases serum creatinine. -Loss of at least 50% of kidney function

When does kidney disease occur?

-Kidney disease results when kidneys cannot remove the body's metabolic wastes or perform their regulatory functions. -The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, affecting endocrine and metabolic functions as well as fluid, electrolyte, and acid-base disturbances

What happens during RAAS?

-Kidneys sense they aren't getting enough blood flow → start the Renin → Pituitary puts out the ADH to save water → Adrenal Cortex saves aldosterone → increases the Na → water increases → Blood pressure rises → Baroreceptors/osmoreceptors are happy → ANP/BNP rise → Kidneys perfused → System stops = body happy and homeostasis achieved

What are the types of peritoneovenous shunts? (don't need to memorize, just know concept)

-LaVeen: valve opens in peritoneum in response to increased fluid pressure -Denver: SQ pump can be manually compressed

What are the types of cirrhosis?

-Laennec's: alcohol (most common) -Post-necrotic: hepatitis or poison when not treated -Biliary: gallbladder problems that backs into liver (not common) -Cardiac cirrhosis: backup of blood flow problem from HF

What are the neuro manifestations of chronic kidney disease?

-Lethargy -Confusion -Seizures -Neuropathy -Restless leg syndrome -Tremors -Ataxia -Coma The more severe the metabolic acidosis, the more severe the neuro sxs

What is direct (conjugated, water soluble) bilirubin?

-Liver converts unconjugated to conjugated -Most excreted in urine or stool -Scant found in blood

What does low BUN/Cr ratio indicate?

-Liver disease -Malnutrition

What are the diagnostic tests for the liver?

-Liver scan (blood flow) -CT/MRI (structure) -Percutaneous liver biopsy (degree of infection or damage)

What are the types of IV accesses needed for shock management?

-Lots of PIV (large bore peripheral IVs) -Central venous catheter (CVC) -Arterial line -Pulmonary artery line (PA cath) in cardiogenic shock or if unsure of shock

How do you manage rhabdomyolysis?

-Lots of fluid (100-200 ml/hr) -Osmotic diuretic -Bicarb

What are the diagnostic findings of primary hypothyroidism?

-Low T3 -Low T4 -High TSH

What are the diagnostic findings of secondary hypothyroidism?

-Low T3 -Low T4 -Low TSH

What is the urine and seurm osmolality like in a patient with DI?

-Low urine osmolality (<100 mosm/kg) -Increased serum osmolality (>295 mosm/kg)

What might be prescribed vitamins for a cirrhosis patient and why?

-MVI or prenatal -High is folate and thiamin which helps prevent neuro problems

Where do the different diuretics act?

-Mannitol, Acetazolamide: proximal convoluted tubule and proximal straight tubule -Bumetanide, Ethacrynic Acid, Furosemide: thick ascending limb of Henle's loop -Thiazide, Metolazone: distal convoluted tubule (closer to ascending limb of Henle's loop) -Amiloride, Spironolactone, Triamterene: distal convoluted tubule (closer to collecting duct)

What is treatment of sepsis like?

-Measure lactate level -Obtain blood cultures before administering antibiotics -Administer broad-spectrum antibiotics -Begin rapid administration of 30ml/kg of crystalloid for hypotension or lactate >3.9 mmol/L -Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP >65 mm Hg -1 hour to implement everything once you see pt is in sepsis

What is the nursing assessment like for pre-dialysis?

-Measure/record VS -Measure/record weight -Assess hemodialysis access (bruit and thrill with AVF and AVG) -Discuss any problems since last run (nausea, vomiting, headache, respiratory problems) -Determine which meds to give or hold

What are the triggers for SIRS?

-Mechanical tissue trauma: burns, crush injuries, surgical procedures -Abscess formation: intraabdominal, extremities -Ischemic or necrotic tissue: pancreatitis, vascular disease, MI -Microbial invasion: bacteria, viruses, fungi -Endotoxin release: gram-negative bacteria -Global perfusion deficits: postcardiac resuscitation, shock states -Regional perfusion deficits: distal perfusion deficits

What is the morality like for HHS?

-Medical emergency! -Morality 10-40% due to advanced age, NH residency, hyperosmolalrity, and hypernatremia

What are ABGs like in chronic renal failure?

-Metabolic acidosis -Low bicarb -Kidneys unable to excrete acid or retain HCO3 -Complicated by hyperkalemia

What are the diagnostic findings in DKA?

-Metabolic acidosis (due to production of ketones and lactic acid) -Blood glucose levels: 300-800 mg/dl -Ketones in urine -Electrolyte imbalances (depends on amount of fluid loss) -Increased anion gap

What is the nursing care like for edema and ascites?

-Monitor I&O -Daily weight -Measure abd girth -Restrict Na and fluids -Monitor labs and diagnostics (acute) -Administer diuretics -Monitor for infection -Bedrest

What is included in the general nursing care for kidney failure?

-Monitor I&O, VS and daily weight -Provide high CHO, low fat diet (protein is variable) -Restrict fluid intake based on urine output -Balance activity with rest -Prepare patient for dialysis -Monitor dialysis access -Provide skin care -Provide emotional support -Encourage pt to ask questions and verbalize concerns -Encourage pt to be compliance with exercise, diet, and meds -EKG monitoring (especially in acute!) -Seizure precautions

What is the nursing care like for bleeding esophageal varices?

-Monitor VS and hematocrit -Establish IV access to replace volume loss -Administer non-selective beta blocker (propranolol) -Administer vasoconstrictors (vasopressin or octreotide) -Administer nitrates -Prepare for emergent invasive interventions

What is the general nursing care like for cirrhosis?

-Monitor labs and diagnostics -Provide teaching/support -Promote adequate nutrition -Administer prescribed vitamins -Avoid hepatotoxic drugs -Use cautions in drug administration -Maintain skin integrity/bed rest -Administer thiamine (vit B1) and librium or ativan for pt with alcoholism -Refer to community resource to stop drinking for pt with alcoholism

What is the nursing care like for hepatic encephalopathy?

-Monitor serum ammonia levels -Frequent neuro assessments -Administer meds -Moderately restrict protein at this point!

What is the major different between early and late septic shock?

-More clearly defined compensation -More definitive lab values

Who can get HHS?

-More common in type 2 DM -Can occur in type 1 DM -Typically occurs in middle-aged or elderly type 2 diabetes who produce enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and ECF deficit

What are advantages of peritoneal dialysis?

-More consistent control -Less time and fatigue -Good for people that cannot take off 4-5 hours of work 3x a week

Who can DKA happen in?

-Most commonly in type 1 DM -Can occur in type 2 DM

What medications would be given/held before hemodialysis?

-Most medications can be held besides pain meds and phosphate binders -Dont want to give BP meds since we are removing liters of fluid and BP will tank

What is rhabdomyolysis?

-Muscle damage and cell destruction causing myoglobin in urine -Doesn't start as kidney disease

What are the musculoskeletal manifestations of chronic kidney disease?

-Muscle weakness -Muscle cramps -Osteodystrophy -Fractures

What are the nursing implications for giving hypertonic saline in a patient with SIADH?

-Must draw frequent Na levels -Do not increase Na by more than 12 meq in 24 hours

What are the nephrotoxic drugs that patients should avoid to prevent ARF?

-NSAIDs -Specific antibiotics (aminoglycosides [-cin's] and vanco) -Contrast dye -Heavy metals

How is Na corrected in SIADH?

-Na of 125-135 meq/L: fluid restriction -Na <100 meq/L: hypertonic saline (3% NaCl)

What medications prevent nephrotoxic effects of contrast medium?

-NaHCO3 (bicarb) -Mucomyst (acetylcysteine)

What are the GI manifestations of chronic kidney disease?

-Nausea -Anorexia (don't feel like eating) -Vomiting -Metallic taste -Stomatitis -Diarrhea -Uremic halitosis -Gastritis

What are disadvantages of peritoneal dialysis?

-Need ability to move around home, pick up dialysis stuff, use asepsis, etc -Takes > 36 hours for therapeutic effect

What are important nursing implications for pituitary resection?

-Need to monitor for DI!! ^I&Os! -Not many post op complications -Not much pain

What are the medications given to someone with hepatic encephalopathy?

-Neomycin (unless in renal failure) or metronidazole -Lactulose

What is disequilibrium syndrome?

-Neuro symptoms from rapid solute transfer headache, confusion, seizure, coma -Happens since they are getting rid of so much in a short amount of time

What are the clinical manfestations of hyperthyroidism?

-Neuro: ^increased irritability ^nervousness -CV: ^tachycardia ^dysrhythmias (a fib) ^palpitations ^HF -Resp: ^tachypnea -Musculoskeletal: ^tremors -Hyperactivity -Heat intolerance

What are the clinical manifestations of hypothyroidism?

-Neuro: ^lethargy ^hearing loss ^hypothermia -CV: ^bradycardia ^hypotension -Resp: ^dyspnea on exertion -Musculoskeletal: ^muscle cramps -Integumentary: ^hair loss ^dry skin

What are the clinical manfiestations of SIADH?

-Neuro: ^weakness ^lethargy ^mental confusion ^seizures ^coma -CV: ^HTN from hypervolemia -Pulmonary: ^dyspnea ^pink frothy sputum ^tachypnea -Increased urine osmolality (>100 mosm/kg) -Decreased serum osmolality (<280 mosm/kg) -Hyponatremia (<135 meq/L) -Increased urine Na (>20 meq/L)

What is the treatment like for hypoglycemia?

-No IV access/can tolerate PO: 15g of fast acting carbohydrates -Severe/can't tolerate PO: 1mg of glucagon SQ/IM or 50 ml dextrose 50% in water (D50) IV

What are the diagnostic findings in HHS?

-Normal ABG (potentially metabolic acidosis depending on how high lactic acid is) -Blood glucose: 600-1200 mg/dl -No or very low Ketones in urine -Electrolyte imbalances (depending on amount of fluid loss)

What does ascites look like?

-Not 50 yr old with beer belly -Liters of fluid backed up in peritoneal space

What is included during post-dialysis nursing assessment?

-Note vital signs -Note weight (hemodialysis nurse will tell you they took off so many liters of fluid, but we will need to weigh when pt returns) -Monitor for complications

What are synthetic grafts and what are they used for?

-Nylon -Wound adherence until spontaneous epithelialization (pt can generate their own skin tissue) -Protects against fluid loss and bacterial invasion

What are the causes of DIC?

-Obstetric issues (when placenta breaks apart-abruptio) -Trauma -Liver failure -Sepsis -Burns -Cancer

What are the nursing implications of paracentesis?

-Obtain consent and provide teaching -Have pt void first to avoid puncturing anything else in the body -Monitor post-op VS and puncture site -Record procedure, character, and volume of fluid as well as patient tolerance

What is the difference between osmolality and osmolarity?

-Osmolality: how many particles in a kg -Osmolarity: how many particles in a L

What is the sensation/healing like for full thickness burns?

-Pain may or may not be present -Painful sensations return and severity of pain increases as the burn heals -Heals within weeks to months -Scarring -Grafting required

What is the sensation/healing like for superficial partial thickness burns?

-Painful -Heals within 10-21 days -No scarring

What is the sensation/healing like for superficial burns?

-Painful -Heals within 3-6 days -No scarring

What is the sensation/healing like for deep partial thickness burns?

-Painful -Sensitive to touch -Heals within 3-6 weeks -Scarring likely -Possible grafting involved

What is type 1 diabetes?

-Pancreas produces little to no insulin -May be due to genetics or an autoimmune response

What is an autograft and what is it best for?

-Patient's own skin -Best for face and functional areas -Best for vascular granulation -Sheet or mesh

What is cultured epitherlial autograft?

-Patient's own skin when they don't anywhere to piull from, so they grow their own

What patients are at risk for ARF?

-People that want to overdose on ibuprofen, aleve, etc because it will destroy kidneys -Pt who already have kidney issues

What is the specific treatment like for obstructive shock?

-Pericardiocentesis -Chest tube -TPA -Surgery

What are the potential complications of peritoneal dialysis?

-Peritonitis -Leakage -Bleeding -Hernias -Back pain

What are the types of temporary vascular access?

-Permacath -Life site catheter

What is sodium polysterene?

-Permanent K removal -Given daily to remove K so it doesn't accumulate in the blood

What is the treatment like for hyperthyroidism?

-Pharmacologic therapy -Radioactive idione -Surgical management

What is a pituitary resection?

-Physician removing pituitary tumor through nose and sinus -Nasal trumpet (circular clear thing) goes into nose

What is the appearance like for superficial partial thickness burns?

-Pink to red -Blisters -Mild to moderate edema -No eschar

What is the appearance like for superficial burns?

-Pink to red -Tender -No blister -Mild edema -No eschar

What are the major hormone secreting glands of the endocrine system?

-Pituitary -Adrenal -Thyroid -Pancreas

What are the types of blood products given to a patient with DIC?

-Platelets (#1) since they are using up all theirs -Fresh frozen plasma (FFP) because it has all the clotting factors plus volume expansion -Factor VIII (cryoprecipitate) additionally since it is destroyed when FFP was frozen -RBC's if they are lost from hemorrhaging (definitely not the most important)

What are the expected diagnostics for DIC?

-Platelets decreased (150,000) -Fibrinogen decreased (less than 203) -Protime/PT prolonged (greater than 14 seconds) -PTT prolonged (greater than 35 seconds) -Anti-thrombin III decreased -FDP (Fibrin Degradation Products or FSP (Fibrin Split Products) greater than 40 -D dimer increased (greater than 250 mg/ml)

What are the clinical manifestations of DI?

-Polyuria (>250ml/hr) -Hypernatremia (serum Na > 145meq/L) -*Hypovolemia -*Hypotension -*Tachycardia * = occur if pt thirst response in not intact

What are the clinical manfestations of DKA?

-Polyuria (inc urine output) -Polydipsia (inc thirst) -Polyphagia (inc hunger) -Nausea and vomiting -Abdominal pain -Restlessness -Confusion -Agitation -Decreased LOC -Visual disturbances -Kussmaul respirations -Fruity breath odor

What are the clinical manifestations of HHS?

-Polyuria (inc urine output) -Polydipsia (inc thirst) -Polyphagia (inc hunger) -hypotension -Restlessness -Confusion -Agitation -Decreased LOC -Visual disturbances

What are the renal manifestations of chronic kidney disease?

-Polyuria and nocturia (early) -Oliguria and anuria (late) -Proteinuria and hematuria (not as common)

What does liver failure cause problems with?

-Portal HTN → ascites and esophageal varices -Hepatic encephalopathy -Jaundice -Bleeding times

What causes esophageal varices?

-Portal vein feeds around GI system → high pressure in venous system from portal HTN → leads up to esophagus → vessels dilate and swell, walls weakened

What might you use in fluid resuscitation?

-Possible colloid use -Isotonic only stay in for like 30 minutes because of loss of cellular integrity, so they might need more

What are the electrolyte serum lab diagnostics?

-Potassium -Sodium -Phosphorus -Magnesium -Calcium (total, ionized)

Why is potassium a low amount in the blood while sodium has a high amount in the blood?

-Potassium is a primary intracellular ion. It is happiest inside cells, not floating in serum -Sodium is a primary extracellular ion

What are the complications of liver transplantation?

-Pre-existing systemic problems -Bleeding -Infection -Rejection

What are the causes of acute renal failure?

-Prerenal (hypoperfusion) -Intrarenal (tissue damage/ATN) -Postrenal (obstruction of urine flow)

How do you prevent ARF?

-Prevent causative factors -Recognize pts at risk -Limit nephrotoxic drugs

Why do we place post-op renal transplants in a reverse isolation/neutropenic precaution room?

-Prevention of US giving PATIENT infection is a priority -Remove invasive devices ASAP -No plants, fresh fruits/veggies in room

What causes MODS?

-Primary: direct injury -Secondary: results from SIRS or sepsis

What are the causes of hypothyroidism?

-Primary: disorder of thyroid gland itself ^Autoimmune thyroiditis (Hashimoto's) ^Post thyroidectomy -Secondary: disorders of pituitary gland

What is the fluid resuscitation like for patients with DKA?

-Priority! -Usually use .9% NaCl or .45% NaCl -Add D5W to IV fluids when glucose is less than 250 mg/dL -Fluid infusion is 150 ml/hr -Monitor for overcorrection -May require 6-10L in separate IV from insulin infusion -Prevent rapid fall in ECF osmolarity with NS (start with 0.5-1L/hr for 2-3 hours, and then 200-500 ml of .45% for several hours) -May need plasma expanders

What can a high alkaline phosphatase level indicate?

-Problem with gallbladder (bile duct inflammation from gallstone) -The longer and higher the level, the more you worry about backup of bile into liver

What happens during the progressive stage of shock?

-Progressive hypoperfusion → anaerobic metabolism → lactic acid accumulation → metabolic acidosis -Failure of Na/K pump causing cell swelling -Microcirculation dilates to increase blood supply → blood tries to get to capillary beds but stays there causing interstitial edema -Increased capilary permeability → fluid leaks out into interstitial space → blood becomes more viscous and slows → platelet aggregation and further impaired venous return to heart -Point of no return -Body no longer able to compensate -Ischemia develops -Heart might start to fail

Why is lactulose administered for someone with hepatic encephalopathy?

-Promotes excretion of ammonia in stool and decreases pH -Can be administered oral, NG, or by enema

What is the purpose of cortisol?

-Promotes glucose production -Inhibit inflammatory response

What is important for nurses to do for a patient receiving hemodialysis?

-Protect machine while running -Make sure wastes and fluid are not removed too quickly

What is gluconeogenesis?

-Protein breakdown -Ammonia as a byproduct that is normally converted to urea and excreted in urine

What are the goals for treatment of DKA?

-Provide cellular nutrition (insulin therapy) -Restore F&E balance (crystalloid IVs) -Treat underlying cause (can be infection, bacteria feed on glucose) -Prevention (sick day rules)

What is the purpose of peritoneovenous shunts?

-Provide continous reinfusion (drainage) of fluid out of peritoneal space and put into venous system via jugular vein or subclavian -Convenience purpose for someone who may need frequent paracentesis

What are the nursing considerations for DIC?

-Psychosocial support -Pain relief -Prevent vasoconstriction -Frequent labs -Maximize oxygenation and tissue perfusion -Closely monitor VS -Watch for MODS -Need central & arterial lines (can be challenging bc of bleeding but they'll need it) -Often intubated

What should the nurse remember about pain management in a burn patient?

-Pt can end up with PTSD just from the pain of the burns. -Undergo incredibly painful showers everyday from sloughing off skin

What are the effects of MODS on the different body systems?

-Pulmonary: ARDS -Cardiac: CO -Hematologic: DIC -Renal: ATN -Liver: liver failure -Brain: seizures/coma -Metabolic: acidosis -GI: intolerance to feeds

What is the purpose of balloon tamponade?

-Puts direct, internal pressure on the bleeding spot -Emergency management only -Can suck out bleed from stomach too?

What is the fluid resuscitation like when treating HHS?

-Rapid IV fluids -Requires more than DKA -6-20L for the first 24 hours with .9% for the first 2 liters, and then .45% if serum Na is over 140 meq/dL -Watch for overload

What is acute kidney injury (AKI)?

-Rapid loss of renal function due to damage to the kidneys wide range of potentially life-threatening metabolic complications can occur like metabolic acidosis and fluid&electrolyte imbalances -Replaced the term acute renal failure because it better describes this syndrome in pts

What is the appearance like for full thickness burns?

-Red to tan, black, brown, or white -No blisters -Severe edema -Hard, inelastic eschar

What is the appearance like for deep partial thickness burns?

-Red to white -Moderate edema -No blisters -Soft and dry eschar

What are the functions of the kidney?

-Regulation of fluid volume -Regulation of electrolyte balance -Regulation of acid-base balance -Regulation of BP -Excretion of nitrogenous waste products -Regulation of erythropoiesis -Metabolism of vitamin D

What does TIPS do?

-Relieves congestion of liver -Reduces portal hypertension (therefore reducing ascites and varices) -Doesn't correct cirrhosis but helps consequences of cirrhosis

What is the specific treatment like for anaphylactic shock?

-Remove antigen -Epinephrine -Diphenhydramine -Steroids

What are the advantages of hemodialysis?

-Requires 12-15 hrs/week compaired to 48+ hours a week that is required in peritoneal dialysis -Can be used with peritoneal dialysis is contraindicated (peritonitis and abdominal lesions) -Rapid results -Less protein loss than with peritoneal dialysis -No dietary resitrctions

What is the purpose of aldosterone?

-Retains Na -Excretes K and hydrogen

What are the sxs that chronic kidney disease patients warrant immediate attention?

-Retention of wastes -Hyperkalemia -Access problems

What are the hepatotoxic drugs?

-Rifampin -Valproic acid -Haloperidol -Phenytoin -Acetaminophen

What are the different ways we can measure burns?

-Rule of 9's -Palmar method -Lund and Browser chart (similar to 9s but more specific)

What is the criteria for septic shock?

-SBP <90 mmHg or MAP <65 mmHg -Urine output <0.05 ml/kg/hr for 2 hours or creatinine >2 mg/dl -Creatinine >0.55 mg/dl above baseline if hx of CKD -Platletes <100,000 mm3 -INR > 1.4 or aPTT > 60 sec -Lactate >4 mmol/L or serum lactate >3 mmol/L after fluid resuscitation -Increasing oxygen requirements -Altered mental status

What is important for nurses do for patients in the compensatory stage of shock?

-See sxs and stop it before the next phase -Trend all VS and outputs

How do the lab values compare between DKA and HHS?

-Serum Glucose: DKA: >300 mg/dL HHS: >600 mg/dL -K+: DKA: initially low, but increases w/ acidosis HHS: low due to diuresis -Na+ DKA: decreased or varied HHS: increased -BUN & Cr: increased in both -Ketones: DKA: present HHS: absent -Serum Osmolarity: DKA: High (>300) HHS: Very high (>350) -Serum pH: DKA: acidosis HHS: normal, possibly mild acidosis from lactic acid

What are the nitrogenous waste blood lab diagnostics?

-Serum creatinine -BUN -BUN/Cr Ratio -Uric Acid

What is seen during the oliguric phase of ARF?

-Severe biochemical imbalances -Hyperkalemia (peaked T waves) -Increase BUN and creatinine (azotemia) -Metabolic acidosis -Low Ca -High phosphate -Anemia

What should the AST and ALT levels be?

-Should be less than 35u/L -The higher they get, the worse the function is

What are the nursing interventions for peritoneal dialysis?

-Site care with soap and water (asepsis) -Promote drainage

What are the important nursing interventions when managing shock?

-Skin integrity -Body temp managment -Psychological -Environmental control (crowd control)

What are the electrolyte urine lab diagnostics?

-Sodium -Protein

What happens during inflow in peritoneal dialysis?

-Solution infused via catheter into peritoneal space -Gravity or by machine

What are the diuretics we would give to patients with edema/ascites?

-Spironolactone -Other diuretics and possible albumin

What are the stages of AKI?

-Stages 1-3 -Serum creatinine steadily increases while GFR and UOP decrease -1: risk stage -2: injury stage -3: failure stage

What is the purpose of oxytocin?

-Stimulates contraction of pregnant uterus -Stimulates milk ejection from breasts after childbirth

What are the different depths of burn?

-Superficial (1st degree burn, like sunburn) -Superficial or deep partial thickness (2nd degree, some dermis) -Full thickness (3rd degree, all dermis) -Worse full thickness (4th degree, into the muscle/bone)

What is the treatment like for Addison's Disease?

-Support circulation (IV fluid resuscitation, vasopressors) -Electrolyte replacement -Antibiotics if an infection is present -Hormone replacement

What is escharotomy?

-Surgical incision of eschar or burned tissue to relieve pressure on extremities after burns -Allows for expansion and blood flow in compartment syndrome due to eschar -Skin is not viable and needs to be removed

What happens during the compensatory phase of shock?

-Sustained decreased perfusion → -Barorecptors and chemoreceptors activates ANS (one of the first compensatory mechanisms) -RAAS activation -Glycogenolysis/gluconeogenesis -V/Q imbalance -Symptoms apparent as body tries to compensate

What are the intrarenal causes of ARF/AKI?

-Sustained prerenal ischemia -Glomerulonephriti, acute glomerulonephritis, or other primary disease of the glomeruli -Acute tubular necrosis (can be caused by diabetes mellitus bc of prolonged hyperglycemic state) -Intravenous contrast -Nephrotoxic drugs: aminoglycosides (gentamycin, tobramycin, vancomycin, NSAIDs, ACE inhibitors)

What is Desmopressin?

-Synthetic ADH -Does not have vasoconstrictor effects -Has long antidiuretic action (12-24 hours)

What is SIRS?

-Systemic inflammatory response syndrome -Systemic inflammatory response to a variety of insults -Generalized inflammation in organs remote from the initial insult

What are the main hormones of the thyroid gland?

-T3 and T4 -Calcitonin

What is the criteria for SIRS?

-Temp <96.8F/36C or >100.4F/38C -HR >90 -RR >20 (tachypnea) or PaCO2 of <32 mmHg -WBC <4,000mm3 or >12,000/mm3 or >10% immature neutrophils (bands)

What are the characteristics of the catheter in peritoneal dialysis?

-Tenckhoff catheter -Tunneled subQ -Permanently sutured into the peritoneal space below the umbilicus -Held in place by 2 cuffs -Cuffs and tunneling decrease infection

Why are critically ill patients at high risk for hyperglycemia?

-The bodies normal stress response increases blood glucose levels -Medical conditions such as DM, obesity, and pancreatitis -Medications like glucocorticoids, catecholamines, and dextrose solutions

What happens during dwell time in peritoneal dialysis?

-The prescribed amount of time fluid remains instilled -Allows for diffusion and osmosis -The longer the dwell time, the more fluid will be removed

What is dialysis?

-The procress of removing wastes from blood by using a semipermeable membrane (peritoneum for PD and artificial membrane dialyzer for HD) that allows particles of varying sizes to pass through. -Solute particles move toward the solution with a lesser concentration (diffusion) -Water moves toward the solution with greater solute concentration (osmosis) -Ultrafiltration uses pressure to remove fluid and waste

What is peritoneal dialysis?

-The surface of the peritoneum acts as a diffusing membrane between abdominal capillary beds & the dialyzing fluid. -Can be done through gravity or a machine -Much more passive that hemodialysis

Why do elderly and young children have a higher risk for mortality from burns?

-Thin skin can lead to deeper burns and more complications -Decrease ability to quickly/effectively move from dangerous situations

What is the purpose of radioactive iodine?

-To destroy thyroid cells -Initial dose increases thyoid hormones

What is liver transplantation like?

-Total removal of diseased liver -Replace with healthy liver in same location -Can have live R lobe transplant -Immunosuppression required

What are the causes of rhabdomyolysis?

-Trauma -Compartment syndrome -Electrical burns -Anything that causes massive muscle damage (ex: crash injury to muscle, excessive crossfit, ultra marathon)

What is the specific treatment like for hypovolemic shock?

-Treat underlying cause -Restore intravascular fluid volume

What is the treatment like for SIADH?

-Treating underlying disorder: ^surgical removal/radiation/chemo of cancer ^d/c the responsible medication -Correcting Na -Fluid balance

What happens during MODS?

-Two or more organ systems fail -Homeostasis cannot be maintained without intervention

What should you monitor in a patient receiving fluid resuscitation?

-Urine output (titrate 0.5 ml/hr) -BP, HR -Lactate levels -Be careful of overhydration

What happens during the diuretics phase of ARF?

-Urine output is greater than 400 ml/day (FVD) -Chemistries begin to stabilize -Marked by gradual increase in urine output, which signals that glomerular filtration has started to recover. -Although output may reach normal or elevated levels, renal function may still be markedly abnormal

What is important to remember about fluid calculations?

-Use dry weight -Use isotonic fluids (LR) since pt do better with the lactate in there -Calculated for 24 hours (1/2 in the first 8 hours, other 1/2 in remaiing 16 hours)

What is peritoneal dialysis like with an octopus (cycler)?

-Used in hospital -Has multiple tubings and bags -Dialysis nurse sets up -Staff nurse never opens or disconnects system, they just monitor the dialysis and the patient

What is creatinine clearance?

-Used to estimate GFR -Most suggestive of renal failure -24 hour urine collection

What should be assessed when treating DKA?

-VS -Tissue turgor -Cardiac rhythm (monitor) -CVP -Acid-base balance

What is the intradialysis nursing assessment (during hemodialysis)?

-VS and BP every 15 min every 1 hour (monitor closely for hypotension!) -Monitor for and treat complications -Provide comfort and diversion -Watch for technical system problems

What is used to optimize afterload in shock patients?

-Vasoconstrictors (phenylephrine, norepinephrine, epinephrine, vasopressin) -(Cardiogenic) IntraAortic Balloon Pump (IABP) to get blood to coroanry arteries

What are the post-op nursing actions for a pt after renal transplant?

-Vital signs -Monitor invasive lines -System assessment -Reverse isolation to room -Medicate with immunosuppresents and aspirin -Assess for sxs of rejection

What is the treatment like for DI?

-Volume replacement -Hormone replacement (Desmopressin (DDVAP)) -*Na restriction -*Thiazide diuretics * = treatment for nephrogenic DI

What is serum creatinine?

-What muscles make when creatinine is broken down to product energy -Kidneys filter it from the body into the urine

When is moving a patient to the burn center indicated?

-When partial thickness burns >10% -Any full thickness -Any face, hands, deet, peri area (these require extensive rehab) -Chemical/electrical -Inhalation of smoke (carbon monoxide/cyanide) -Associated trauma like trapped motor vehicle caught on fire

What does the KUB show?

-Will tell you how many kidneys -Allows for visualization of structures and to detect renal calculi, strictures, calcium deposits, or obstructions

What happens during the refractory stage of shock?

-Worse everything leadings to all organs sying -SIRS and MODS lead to death -Prolonged, inadequate perfusion → organ dysfunction → organ failure → death

What does a long duration of the oliguric phase indicate?

-Worse prognosis -Increased risk of progressing to CRF (FVE) -Why it is important to recognize oliguric phase ASAP!

What are the skin manifestations of chronic kidney disease?

-Yellow cast to skin -Pruritis -Bruising -Uremic frost -Hard -Dry and flaky -Itchy

What are the zones of burn injury?

-Zone of coagulation: where cellular death occurs and sustains the most damage -Zone of stasis: compromised supply of blood, inflammation, and tissue injury -Zone of hyperemia: sustains the least damage

What are the normal ABG values?

-pH: 7.35-7.45 -PCO2: 35-45 mmHg -HCO3: 22-26 mEq/

What is the normal range for urine protein?

0-8 mg/dL

What is the normal range for total bilirubin?

0.3-1.3mg/dL

What is the normal serum creatinine range?

0.7-1.4 mg/dL

What are the phases of acute renal failure?

1. Initiation 2. Oliguric (lasts 10-20 days) 3. Diuretic (10 days) 4. Recovery (3-13 months)

What are the 3 steps of urine formation?

1. Prerenal: delivery of blood for ultrafiltration/glomerular filtration 2. Intrarenal: processing of ultrafiltrate by tubular secretion and reabsorption 3. Postrenal: excretion of kidney waste products through the ureters, bladder, and urethra

What is the normal range for serum magnesium?

1.3-2.5 mg/dl

What is the normal BUN range?

10-20 mg/dL

What is the normal urine osmolality range?

100-900 mosm/kg

What is the normal BUN/Cr ratio?

10:1-20:1

What is the normal prothrombin time range?

11-14 seconds

What is the normal range for serum sodium?

135-145 mEq/L

What are the normal serum ammonia levels?

15-45 mcg/dL

How long does it take for AV graft to mature (heal and be ready to access for hemodialysis)?

2-4 weeks to mature

What is the normal uric acid range?

2-7.5 mg/dL

What is the normal range for serum phosphorus?

2.5-4.5 mg/dl

What is normal urinary cortisol like?

24 hour urine test shows 4-40mcg

The physician prescribes Regular insulin 50 units in 250 ml of NS to infuse at 5 units per hour. How many ml per hour does the nurse infuse this solution?

25 ml/hr

What is the normal serum osmolality?

280-300 mOsm/kg

What is the normal serum osmolality range?

280-300 mosm/kg

What is the normal range for serum potassium?

3.5-5.5 mEq/L

What is the normal albumin level range?

4-6g/dL

What is the normal range for ionized (free) serum calcium?

4.5-5 mg/dl (active)

What should alkaline phosphatase levels be?

45-145u/L

What is the normal protein (in urine) range?

50-80mg/24 hours

What is the mortality rate like in MODS?

54%

What is the normal range for urine sodium?

75-200 mEq/dau

What is the normal range for total (free and protein bound) serum calcium?

8.6-10.2 mg/dl

What is the normal GFR?

80-125 ml/min = 180 L/day (50 gallons)

What is the normal range for creatinine clearance?

88-137 ml/min

What % of fluid that is filtered by the kidneys is reabsorbed?

99% (this is why we don't pee out 50 gallons of water a day)

What is HCO3 like in DKA?

<15 mEq/L

What is HgbA1C like in DKA?

>7%

What is toxic adenoma?

A functional growth on thyroid gland, in which hormone production is independent from TSH

Why do we need to monitor for DI in patients post pituitary resection?

A part of the pituitary gland is removed, so they might not be able to product enough ADH.

A nurse is preop teaching with a pt who is scheduled for a kidney transplant about rejection of a transplanted kdiney. Which of the following statement should the nurse include in the teaching? (Select all that apply). A. "Expect an immediate removal of the donor kidney for hyperacute rejection." B. "You may need to begin dialysis to monitor your kidney function for a hyperacute rejection." C. "A fever is a manifestation of an acute rejection." D. "Fluid retention is a manifestation of an acute rejection." E. "Your provider will increase your immunosuppresive medication for a chronic rejection"

A. "Expect an immediate removal of the donor kidney for hyperacute rejection." C. "A fever is a manifestation of an acute rejection." D. "Fluid retention is a manifestation of an acute rejection." -Immediate removal of the donor kidney is treatment for hyperacute rejection -Dialysis can be required as a conservative treatment to monitor the client's kidney function for the progression of chronic kidney failure following kidney transplant -Fever is a manifestation of an acute rejection -Fluid retention is a manifestation of an acute rejection -Immunosuppressants are increased to treat an acute rjection

A pt who is scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the client's risk of surgery? (Select all that apply). A. Age older than 70 yrs B. BMI of 41 C. Administering NPH insulin each morning D. Past hx of lymphoma E. Blood pressure averaging 120/70 mm Hg

A. Age older than 70 yrs B. BMI of 41 C. Administering NPH insulin each morning D. Past hx of lymphoma -A pt older than 70 yrs has an increased risk for complications from surgery, lifelong immunosuppresion, and organ rejection -A pt who has BMI of 41 is morbidly obese and is at an increased risk for complications of surgery, lifelong immunosuppression, and organ rejection -A pt who requires NPH insulin for type 1 DM is at increased risk for complications of surgery, lifelong immunosuppression, and organ rejection -A pt who has a hx of cancer, such as lymphoma, is at increased risk for complications of surgery, lifelong immunosuppression, and organ rejection -BP averaging 120/70 is within the expected reference range and does not place the client at greater risk for those

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply). A. Anuria B. Marked azotemia C. Crackles in the lungs D. Increased calcium level E. Proteinuria

A. Anuria B. Marked azotemia C. Crackles in the lungs E. Proteinuria -Anuria is a manfestation of end-stage kidney disease -Marked azotemia is elevated BUN and serum creatinine, is a manifestation of end-stage kidney disease -Crackles in the lungs can indicate the client has pulmonary edema, caused from hypvolemia due to end-stage kiney disease -Calcium level are DECREASED due to increase in serum phosphate levels when the client has end-stage kidney disease -Proteinuria is a manfestation of end-stage kidney disease

A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply). A. Assess for jugular vein distention B. Provide frequent mouth rinses C. Auscultate for a pleural friction rub D. Provide a high-sodium diet E. Monitor for dysrhythmias

A. Assess for jugular vein distention B. Provide frequent mouth rinses C. Auscultate for a pleural friction rub D. Provide a high-sodium diet E. Monitor for dysrhythmias -The nurse should assess for JVD, which can indicate fluid overload and HF -The nurse should provide frequent mouth rinses due to uremic halitosis caused by urea waste in the blood -The nurse should auscultate for a pleural friction rub related to respiratory failure and pulmonary edema caused by acid base imbalances and fluid retention -The nurse should monitor serum sodium and REDUCE the client's dietary sodium intake -The nurse should monitor for dysrhythmias related to increased serum potassium caused by stage 4 chronic kidney disease

A nurse is planning postprocedure care for a pt who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? (select all that apply). A. Check BUN and serum Creatinine B. Administer meds the nurse held prior to dialysis C. Oberve for signs of hypovolemia D. Assess access site for bleeding E. Evaluate BP on the arm with AV access

A. Check BUN and serum Creatinine B. Administer meds the nurse held prior to dialysis C. Oberve for signs of hypovolemia D. Assess access site for bleeding -Nurse should check BUN and serum Cr to determine the presence and degree of uremia or waste products that remain following dialysis -Nurse should hold meds the treatment can partially dialyze, so they should adminiter after dialysis -Pt who is post-dialysis is at risk for hypovolemia due to a rapid decrease in fluid volume -Nurse should assess the access site for bleeding bc the pt received heparin during the procedure to prevent clotting of blood -Nurse should never measure BP on the extremity with AV access bc it can cause collapse of the AV fistula or graft

A nurse is caring for a pt who has cirrhosis. Which of the following meds can the nurse expect to administer to this client? A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose E. Sedative

A. Diuretic B. Beta-blocking agent D. Lactulose -Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis -Beta-blocking agent are prescribed for a client who has cirrhosis to prevent bleeding from varices -Opioid analgesics are metabolized in the liver. They should not be administered to a client who has cirrhosis -Laculose is prescribed got a client who has cirrhosis to aid in the elimination of ammonia in the stool -Sedatives are metabolized in the liver. The should not administered to client who has cirrhosis

A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all apply) A. Dyspnea B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

A. Dyspnea C. Hyperkalemia D. Hyponatremia -Dyspnea can occur during the initial phase following a burn due to airway injury and fluid shifts -Tachycardia occurs during the inital phase following a burn due to sympathetic nervous system compensation -Hyperkalemia occurs during the initial phase following a burn as a result of leakage of fluid from the intracellular space -Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space -Hct INCREASES during the initial phase of a burn to hemoconcentration

A nurse is caring for a client who has DIC. Which of the following meds should the nurse anticipate administering? A. Heparin B. Vitamin K C. Mefoxin D. Simvastatin

A. Heparin -Heparin can administered to decrease the formation of microclots, which deplete clotting factors -Vitamin K promotes blood coagulation and is not prescribed for a client who has DIC -Mefoxin is an antibiotic given to treat bacterial infection, not DIC -Simvastatin is an antilipemic given to treat hyperlipidemia, not DIC

A nurse is caring for a client with type 2 DM and will have excretory urography. Prior to the procedure, which of the following actions should the nurse take? (Select all that apply). A. Identify an allergy to seafood B. Withhold metformin for 24 hours C. Administer an enema D. Obtain a serum coagulation profile E. Assess for asthma

A. Identify an allergy to seafood B. Withhold metformin for 24 hours C. Administer an enema E. Assess for asthma -Pts who have an allergy to seafood are at higher risk for an allergic reaction to the contrast dyes they will receive during the procedure -Pts who take metformin are at risk for lactic acidosis from the contrast dye with iodine they will receive during the procedure -Clients should receive an edema to remove fecal contents, fluid, and gas from the colon for a more clear visualization -Serum coagulation profile is essential for a client prior to a KIDNEY BIOPSY bc of the risk of hemorrhage, not for urography -Pts who have asthma have a higher risk of an exacerbation as an allergic response to the contrast dye they will receive during the procedure

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care (Select all that apply.) A. Limit visitors in the clients room B. Encourage fresh veggies in the diet C. Increase protein intake D. Instruct the client to consume 2,000 calories a day E. Restrict fresh flowers in the room

A. Limit visitors in the clients room C. Increase protein intake E. Restrict fresh flowers in the room -The nurse should limit the number of visitors and limit the amount of time they can visit to decease the risk of infectoin -The client should restrict consumption of fresh veggies due to the presence of bacteria onthe surface and the increased risk for infection -The client should increase protein consumption, which promotes wound healing and prevents tissue breakdown -Flowers should not be in the client's room due to the bacteria they carry, which increases the risk for infection

A nurse is planning care for a pt who will undergo peritoneal dialysis. Which of the following actions should the nurse take? (Select all that apply). A. Monitor serum glucose levels B. Report cloudy dialysate return C. Warm the dialysis in a microwave oven D. Assess for SOB E. Check the access site dressing for wetness F. Maintain medical asepsis when accessing the catheter insertion site

A. Monitor serum glucose levels B. Report cloudy dialysate return D. Assess for SOB E. Check the access site dressing for wetness -The nurse should monitor serum glucose bc the dialysate solution contains glucose -The nurse should monitor for cloudy dialysate return, which indicates infection. Clear, light-yellow solution is typical during outflow process -The nurse should avoid warmining dialysate in a microwave oven, which causes uneven heating of the solution -The nurse should assess for SOB bc it can indiate inability to tolerate large volume of dialysate -Nurse should check access site dressing for wetness and look for kinking, pulling, clamping, or twisting of the tubing, which can increase the risk for exit-site infections -The nurse should maintain SURGICAL, not medical, asepsis when accessing the catheter insertion site to prevent infection from contamination

A nurse is planning postoperative care for a client followng a kidney transplant surgery. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Obtain daily weights B. Assess dressings for bloody drainage C. Replace hourly urine output with IV fluids D. Expect oliguria in the first 4 hours E. Monitor serum electrolytes

A. Obtain daily weights B. Assess dressings for bloody drainage C. Replace hourly urine output with IV fluids E. Monitor serum electrolytes -Daily weights are obtained to assess fluid status -Drainage on the dressing is assessed to monitor for hemorrhage or hematoma -Hourly urine output with IV fluid replacement is monitored to detect abrupt decrease in urine output, which can indicate rejection or other serious conditions of the transplant kidney -Oliguria can indicate ischemia, AKI, rejection or hypovolemia. Report oliguria immediately to the provider -Serum electroyltes are monitored bc electrolytes loss can occur with postop diuresis

A nurse is caring for a pt who has DIC. Which of the following lab values indicates the pt's clotting factors are depleted? (Select all that apply.) A. Platelets 100,000/mm3 B. Fibrinogen levels 57 mg/dl C. Fibrin degradation products 4.3 mcg/ml D. D-dimer 0.03 mcg/ml E. Sedimentation rate 38 mm/hr

A. Platelets 100,000/mm3 B. Fibrinogen levels 57 mg/dl -Plateletes levels are decreased in DIC causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage -Fibrinogen levels are decreased in DIC causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage -Fibrin degradation produced increased when DIC occurs -A D-dimer level is increased when DIC occurs -The sedimentation rate is increased, but is not an indicator of DIC

A nurse is planning care for a pt who has postrenal AKI due to metastatic cancer. The client has a serum creatinine of 5 mg/dl. Which of the following interventions should the nurse include in the plan? (Select all that apply). A. Provide a high-protein diet B. Assess the urine for blood C. Monitor for intermittent anuria D. Weight the client once per week E. Provide NSAIDs for pain

A. Provide a high-protein diet B. Assess the urine for blood C. Monitor for intermittent anuria -The nurse should provide a high-protein diet due to the high rate of protein breakdown that occurs with AKI -The nurse should assess urine for blood, stones, and particles indicating an obstrution of the urinary structures that leave the kidney -The nurse should assess for intermittent anuria due to obstruction or damage to kidneys or urinary structures -The nurse should weight the client dialy to monitor for fluid retention due to AKI -The nurse should not administer NSAIDs, which are toxic to the nephrons in the kidney

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? (Select all that apply). A. Review the medications the client currently takes B. Assess the AV fistula for a bruit C. Calculate the client's hourly urine output D. Measure the client's weight E. Check serum electroyltes F. Use the access site area for venipuncture

A. Review the medications the client currently takes B. Assess the AV fistula for a bruit D. Measure the client's weight E. Check serum electroyltes -By reviewing meds the client currently takes, the nurse can determine which meds to hold until after dialysis -Assessing for bruit determines the patency of the fistula for dialysis -The clients hourly UOP can vary with the remaining kidney function and doesn't determine the need for dialysis -Measuring the client's weight b4 dialysis is essential for comparing it with the wt after dialysis -Checking the serum electrolytes determines the need for dialysis -Nurse should never use access site area for venipuncture bc compression from the tourniquet can cause loss of the vascular access

A nurse in a providers office is assessing a pt who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full thickness

A. Superficial thickness -A sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin -A superficial partial thickness burn results from flames or scalds. This damages the entire epidermis layer of the skin -A deep partial-thickness burn can result from contact with hot grease. This affects the deep layers of the skin -A full-thickness burn can result from contact with hot tar. This affects the dermis and something subtaneous fat layer

A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). Which findings indicate that the treatment being received are effective? Select all that apply. A. decrease in body weight B. rise in blood pressure and drop in HR C. increase in urine output D. decrease in urine osmolarity

A. decrease in body weight C. increase in urine output D. decrease in urine osmolarity

A client comes to the clinic verbalizing a weight loss of 20lbs over the last month, even with a "ravenous" appetite and no change in activity level. The client is diagnosed with grave's disease. Which other signs and symptoms of graves disease would the nurse assess for? Select all that apply. A. rapid, bounding pulse B. orthopnea C. heat intolerance D. mild tremors E. nervousness F. constipation

A. rapid, bounding pulse C. heat intolerance D. mild tremors E. nervousness

A nurse is caring for a client with Cushing's disease. During change of shift report, which assessment laboratory data would the nurse anticipate communicating? Select all that apply. A. serum sodium level B. hemoglobin and hematocrit C. serum potassium level D. blood glucose level E. white blood cell count F. creatinine clearance total

A. serum sodium level C. serum potassium level D. blood glucose level E. white blood cell count

When will RAAS stop?

When perfusion is good again

When do you typically treat critically ill patients glucose levels?

When they are greater than 180 mg/dl

When are nephrotoxic meds dangerous?

When they are used over 10 days (like antibiotic use) without proper monitoring, or given at inappropriate dosages

What will the serum osmo tell you in a confused patient?

Will tell you the difference between water intoxication and dehydration

How should you passively rewarm a patient with hypothyroidism?

With blankets, not heating pads

Can a patient undergo hemodialysis if they have a temperature?

Yes, and the hemodialysis nurse can pull cultures during dialysis

What is the pathophysiology of ascites?

cirrhosis with portal htn → splanchnic arterial vasodilation → decrease in circulating arterial blood volume → activation of RAAS and sympathetic nervous system and antidiuretic hormone → kidney retains sodium and water → hypervolemia →persistent activation of systems for retention of sodium and water → ascites and edema formation →continued arterial underfilling → cycle repeats

How does sepsis cause DIC?

insult to body causing activation of inflammatory system → coagulation factors become hyperactive and start to form microthrombus → thrombus become lodged into capillary beds → ischemia necrosis in organs and tissues → uses up all coagulation factors → excessive bleeding

What is used in hormonal replacement for hypothyroidism?

levothyroxine sodium (Synthroid), which is synthetic T4

What is the specific gravity, urine osmolality, urine sodium, and BUN/CR ratio like in intrarenal ARF?

specific gravity: 1.010 urine osmolality: <350 urine sodium: >20 BUN/CR ratio: norm

What is the specific gravity, urine osmolality, urine sodium, and BUN/CR ratio like in prerenal ARF?

specific gravity: >1.020 urine osmolality: >500 urine sodium: <10 BUN/CR ratio: elevated

What is the specific gravity, urine osmolality, urine sodium, and BUN/CR ratio like in postrenal ARF?

specific gravity: normal-1.010 urine osmolality: variable urine sodium: normal-40 BUN/CR ratio: norm

What are the signs and symptoms of fluid volume deficit and how is it managed?

sxs: -acute wt loss greater than or equal to 5%, -decreased skin turgor, -dry mucous membranes, -oliguria or anuria, increased hematocrit, -BUN level increased out of proportion to creatinine level, -hypothermia mgmt: -fluid challenge, -fluid replacement orally or parenterally

What are the signs and symptoms of calcium deficit and how is it managed?

sxs: -abd and muscle cramps, -stridor, -carpopedal spasm, -hyperactive reflexes, -tetany, -positive Chvostek or Trousseau sign, -tingling of fingers and around mouth, -ECG changes mgmt: -diet, oral, or parenteral calcium salt replacement

What are the signs and symptoms of fluid volume excess and how is it managed?

sxs: -acute wt gain greater than or equal to 5%, -edema, -crackles, -SOB, -dec BUN, -dec hematocrit, -distended neck veins mgmt: -fluid and sodium restriction, -diuretic agents, -dialysis

What are the signs and symptoms of potassium deficit and how is it managed?

sxs: -anorexia, -abd distention, -paralytic ileus, -muscle weakness, -ECG changes, -dysrhythmias mgmt: diet, oral, or parenteral potassium replacement therapy

What are the signs and symptoms of urine protein deficit and how is it managed?

sxs: -chronic wt loss, -emotional depression, -pallor, -fatigue, -soft flabby muscles mgmt: -diet, -dietary supplements, -hyperalimentation, -albumin

What are the signs and symptoms of phosphorus deficit and how is it managed?

sxs: -deep bone pain, -flank pain, -muscle weakness and pain, -paresthesia, -apprehension, -confusion, -seizures mgmt: -diet, oral, or parenteral phosphorus supplementation therapy

What are the signs and symptoms of calcium excess and how is it managed?

sxs: -deep bone pain, -flank pain, -muscle weakness, -depressed deep tendon reflexes, -constipation, -nausea and vomiting, -confusion, -impaired memory, -polyuria, -polydipsia, -ECG changes mgmt: -fluid replacement, -etidronate, -pamidronate, -mithramycin, -calcitonin, -glucocorticoids, -phosphate salts

What are the signs and symptoms of potassium excess and how is it managed?

sxs: -diarrhea, -colic, -nausea, -irritability, -muscle weakness, -ECG changes mgmt: -dietary restriction, -diuretics, -IV glucose, -insulin and sodium bicarb, -cation-exchange resin, -calcium gluconate, -dialysis

What are the signs and symptoms of sodium excess and how is it managed?

sxs: -dry, -sticky mucous membranes, -thirst, -rough dry tongue, -fever, -restlessness, -weakness, -disorientation mgmt: -fluids, -diuretic agents, -dietary restriction

What are the signs and symptoms of magnesium deficit and how is it managed?

sxs: -dysphagia, -muscle cramps, -hyperactive reflexes, -tetany, -positive Chvostek or Trousseau sign, -tingling of fingers, -dysrhythmias, -vertigo mgmt: -Diet, oral, or parenteral magnesium replacement therapy

What are the signs and symptoms of magnesium excess and how is it managed?

sxs: -facial flushing, -nausea and vomiting, -sensation of warmth, -drowsiness, -depressed deep tendon reflexes, -muscle weakness, -respiratory depression, -cardiac arrest mgmt: -calcium gluconate, -mechanical ventilation, -dialysis

What are the signs and symptoms of sodium deficit and how is it managed?

sxs: -nausea, -malaise, -lethargy, -headache, -abd cramps, -apprehension, -seizures mgmt: -diet, -normal saline or hypertonic saline solutions

What is diabetic ketoacidosis (DKA)?

Acute, life threatening condition characterized by: -uncontrolled hyperglycemia (greater than 300 mg/dl) -metabolic acidosis -accumulation of ketones in the blood and urine

What is hyperosmolar hyperglycemia state (HHS)?

Acute, life-treatning condition characterized by: -profound hyperglycemia (> 600 mg/dL -hyperosmolarity that leads to dehydration -absence of ketosis

What is Addison's disease?

Adrenocortical insufficiency

What are we concerned about when someone has surgery to the thyroid?

Airway! Hematomas can form and cause it to be compromised

What are the clinical manifestations of myxedema coma?

All of the manifestations of hypothyroidism as well as becoming unconscious

What is acute glomerulonephritis?

An inflammatory response resulting in glomerular damage caused by immune disorders (SLE (lupus)) and infection (beta hemolytic strep)

How is the adrenal cortex regulated?

Anterior pituitary releases ACTH →Adrenocorticotropic hormone (ACTH) stimulates adrenal cortex → Adrenal cortex releases Cortisol, Aldosterone, and Adrogens

Where is the thyroid located?

Anterior to trachea

What are the postrenal causes of ARF/AKI?

Any blockages after kidneys -BPH (benign prostatic hyperplasia) -Neoplasms or trauma -Strictures -Obstruction of collecting ducts with crystallization -Renal calculi -Blood clots

What is the normal level for direct bilirubin?

Around 0.3mg/dL

What is the normal level for indirect bilirubin?

Around 1mg/dL

Why is there hyperkalemia in the oliguric phase of ARF?

As fluid leaks out of cells and into serum to balance low fluid level and retain fluid, there is potassium in serum

Why is osteodystrophy a manifestation of chronic renal disease?

As phosphorus elevated and calcium reduces, body uses up every possible source of calcium. When body needs more calcium, it pulls the calcium from the bones (you cannot replace that)

What causes compartment syndrome?

As the taut, burned tissue becomes unyielding to the edema under the surface, it starts to act like a tourniquet, especially if the burn is circumferential. As edema increases, pressure on small blood vessels in the distal extremities causes an obstruction of blood flow and consequent tissue ischemia and compartment syndrome.

Where is the pituitary gland located?

Attached to the bottom of hypothalamus, which is at the base of the brain

What is Graves disease?

Autoimmune disease that is caused by abnormal stimulation of the thyroid gland

A nurse is assessing a pt who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply.) A. Anorexia B. Change in orientation C. Asterixis D. Ascities E. Fetor hepaticus

B. Change in orientation C. Asterixis E. Fetor hepaticus -Anorexia is present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy -A change in orientation indicates hepatic encephalopathy in a client who has advanced cirrhosis -Asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encepalopathy -Ascities can be present in a client who has liver dysfunction, but its not an indication of hepatic encephalopathy -Fetor hepaticus, a fruity breath odor, is a finding of hepatic encephalopathy in the client hwo has advanced cirrhosis

A nurse is reviewing client laboratory data. The nurse should recognize that which of the following findings is expected for a client who has Stage 4 chronic kidney disease? A. Blood urea nitrogen (BUN) 15 mg/dL B. Glomerular filtration rate (GFR) 20 mL/min C. Serum creatinine 1.1 mg/dl D. Serum potassium 5.0 mEq/L

B. Glomerular filtration rate (GFR) 20 mL/min -The nurse should expect the BUN to be above the expected reference range, about 10-20x the BUN finding -The GFR severly decreased to approximately 20 ml/min, which is indicative of stage 4 chronic kidney disease -In stage 4 chronic kidney disease, a creatinine level can be as high as 15 to 30 mg/dl -A client in stage 4 chronic kidney disease would have a potassium level greater than 5.0 mEq/L

A nurse is monitoring a client who has a kidney biopsy for posoperative complications. Which of the following complications should the nurse identify as causing the greatest risk to the client? A. Infection B. Hemorrhage C. Hematuria D. Pain

B. Hemorhage -The pt is at risk for infection of the kdieny bc a biopsy is an invasive procedure, but another complication is the priority -The greatest risk to the client following a kidney biopsy is hemorrhage due to a lack of clotting at the puncture site. The nurse should report this finding to the provider immediately -The client is at risk for hematuria, which is a common complication the first 48 to 72 hr after the biopsy, hoever another complication is the priority, -The client is at risk for pain after a kidney biopsy bc blood in and around the kidney causes pressure on the nerves in the area, however, another complication is the priority.

Why is serum osmolality and serum Na decreased in SIADH?

Because it is being diluted

Why is urine osmolality and urine Na increased in SIADH?

Because it is more concentrated

What secretes insulin?

Beta cells in the pancreas

What is the pathophysiology of jaundice?

Bile not into duodenum → bile reabsorbed instead → stained skin, orange urine, clay-colored stool

What type of drinking causes alcholic cirrhosis?

Binge drinking, not free/casual drinking

What do loop diuretics do?

Block 20-30% of Na reabsorption

What do thiazide diuretics do?

Block 5-10% sodium reabsorption

What do K-sparing diuretics do?

Block less sodium than thiazide, but don't waste potassium

What are the causes of obstructive shock?

Blockage or compression that impairs perfusion -Caused by cardiac tamponade, tension pneumothorax, PE, aortic stenosis

How does low albumin cause edema in late cirrhosis?

Body cannot breakdown protein into forming albumin, and when you have low albumin levels in the body, water likes to stick around

Why is nocturia a manifestation of chronic kidney disease?

Body is resting and can get more perfusion to kidneys at night (in early)

Why can myoglobinuria be seen in patients with burns?

Burned tissue → goes down to muscles or creates tissue damage everywhere → lead to cellular breakdown and clogged kidneys → rhabdomylosis sxs like myoglobinuria

A nurse is teaching a client who is postop following a kidney transplant and is taking cyclosporine. Which of the following instructions should the nurse include? A. "Decrease your intake of protein-rich foods" B. "Take this med with grapefruit juice" C. "Monitor for and report a sore throat to your provider" D. "Expect your skin to turn yellow"

C. "Monitor for and report a sore throat to your provider" -The pt should not decrease protein-rich foods in the diet, which promote healing and rebuilds muscle. There are no restriction of protein for a client taking cyclosporine following a kidney transplant -The client should not drink grapefruit juice, which can reduce cyclosporine metabolism and cause increased cyclosporine levels -The client should report any manifestations of an infection bc thi smed causes immunosuppression -The client should report manifestations of hepatotoxicity, such as jaundice, and abominal pain

A nurse is caring for a pt who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? A. Administer an opioid med B. Monitor for hypertension C. Assess LOC D. Increase the dialysis exchange rate

C. Assess LOC -Altered LOC is a manifestation of disequilirbrium syndrome. The nurse should not give opioid meds. They might prescribe med to decrease seizure activity -Should monitor for HYPOtension due to rapid change in fluids and electrolytes causing disequilibrium syndrome -The nurse should assess the pt's LOC. A change in urea levels can cause increased intracranial pressure, which can decrease their LOC. -Nurse should DECREASE the dialysis exchange rate to slow the rapid changes in fluid and electrolyte status when a client develops disequilibrium syndrome.

A nurse is assessing a client and suspects the client is experiencig DIC. Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

C. Epistaxis -Tachycardia is a finding of DIC -Hypotension is a finding of DIC -Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC -Xerostomia is dryness of the mouth and is not indicative of DIC

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of his body 24 hr ago. The nurse should plan to use which of the following routes to administer the meds? A. Subcutaneous B. Oral C. IV D. Transdermal

C. IV -The nurse should not give subcu injections due to the difficulty of absorption from tissue during the resuscitation phase -The nurse shouldnt give oral (including buccal, sublingual) meds due to decreased motility in the GI tract during the resuscitation phase -The nurse should use IV route to administer pain meds for rapid absorption and fast pain relief during the resuscitation phase -The nurse shouldnt use the transdermal route administration due to delays in absorption duering the resuscitation phase

A nurse is caring for a pt who has sustained burns over 35% of his total body surface area. Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has brassy cough and is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoining

C. Inhalation injury -Difficulty breating and production of pink frothy sputum indicate pulmonary edema -Productive cough and a fever are indicative of a bacterial infection -Wheezing and hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider -Confusion and headaches indicate carbon monoxide poisoning

A nurse administered captopril to a client during a renal scan. Which of the following actions should the nurse take? A. Assess for HTN B. Limit the client's fluid intake C. Monitor for orthostatic hypotension D. Encourage early ambulation

C. Monitor for orthostatic hypotension -Captopril is an antihypertensive med, the nurse should assess for HYPOtensive effects -INCREASING the clients fluid intake can help resolve hypotensive effects following administration of captopril -The nurse should monitor for orthostatic hypotension bc this an adverse effect of captoprtil. This results in a change in blood flow to the kdineys after the initial dose -The pt is at risk for falls when ambulating due to the hypotensive effects of captopril. The nurse should encourage pt to remain in bed

A nurse is reviewing the results of a client's urinalysis. The findings indicate the urine is positive for leukocyte esterase and nitrates. Which of the following actions should the nurse take? A. Repeat the test early the next morning B. Start a 24 hr urine collection for creatinine clearance C. Obtain a clean-catch urine specimen for culture and sensitivity D. Insert an indwelling catheter urinary catheter to collect a urine specimen

C. Obtain a clean-catch urine specimen for culture and sensitivity -Repeating the test early the next morning will not change the results -A 24 hr urine collection for creatinine helps determine kidney function -The nurse should obtain a clean-catch urine specimen for culture and sensitivity. This test will identify which antibiotic will be most effective for treating the client's urinary tract infection -The nurse should insert a urinary catheter to collect urine when a client cannot empty his bladder

A nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hr, and blood pressure is 92/58 mm Hg. The nurse should anticipate which of the following interventions? A. Prepare the client for a CT scan with contrast dye B. Plan to administer nitroprusside C. Prepare to administer a fluid challenge D. Plan to position the client in Trendelenburg

C. Prepare to administer a fluid challenge -The nurse should not plan for a CT scan. Contrast dye in contraindicated for a client who has possible AKI -Nitroprusside is a rapid-acting vasodilator used to rapidly reduce blood pressure for clients who have hypertensive crisis. Its contraindicated for clients who have hypotension -The nurse should plan to administer a fluid challenge for hypovolemia, which is indicated by the client's low urinary output and blood pressure -The nurse should position the client in reverse Trendelenburg, with the head down and feet up, to treat hypotension

A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply). A. Reduced BUN B. Elevated cardiac enzymes C. Reduced urine output D. Elevated serum creatinine E. Elevated serum calcium

C. Reduced urine output D. Elevated serum creatinine -A manifestation of prerenal AKI is an elevated BUN caused by the rention of nitrogenous wastes in the blood -Elevated cardiac enzymes is a manifestation of cardiac tissue injury, not AKI -A manifestation of prerenal AKI is reduced urine output -A manifestation of prerenal AKI is elevated serum creatinine -A manifestation of prerenal AKI is reduce calcium level

When caring for the patient with DKA, which nursing diagnosis takes priority? A.Anxiety B.Knowledge deficit C.Fluid volume deficit D.Risk for injury

C.Fluid volume deficit

Is acute renal failure reversible?

Can be

What can the abrupt stop of corticosteroids cause?

Can cause the adrenal glands to lose the ability to produce cortisol

What is the enzyme that allows bicarb to be produced?

Carbonic anhydrase

What type of shock has high heart pressure (PA cath)?

Cardiogenic shock

Why is HTN a top cause of failure in chronic kidney disease?

Causes chronic hypoperfusion to kidneys, which means chronic activation of RAAS, and the kidneys always saying that they need more perfusion

What is an example of a deep full thickness burn?

Chemical burns

How is bicarb produced?

Chemical reaction between H+ ions, H2O and CO2 produces bicarb within renal tubules

What can acute renal failure progress to?

Chronic renal failure

What does D-dimer show?

Clotting

What might a patient with DI be able to do if their thirst response is intact?

Compensate for the loss of water

In cirrhosis, what does the disorganized pattern of regeneration (hobnail appearance) contribute to?

Contribues to impaired functioning of the liver

What happens to the creatinine clearance when the kidneys aren't working?

Creatinine clearance will be low

A nurse is teaching a client who will have an x-ray of the kidneys, ureters, and bladder. Which of the following statements should the nurse include in the teaching? A. "You will receive contrast dye during the procedure" B. "An enema is necessary before the procedure C. "You will need to lie in a prone position during the procedure" D. "The procedure determines whether you have a kidney stone"

D. "The procedure determines whether you have a kidney stone" -Clients do not receive any constrast dye for this procedure, as they would for excretory urography. -Pts do not receive an edem b4 this procedure bc it does not affect the GI system -The client will lie supine, not prone -The nurse should explain to the pt that a KUB can identify renal calculi, strictures, calcium deposits, and obstructions of the urinary system

A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching? A. Hemodialysis restores kidney function B. Hemodialysis replaces hormonal function of the renal system C. Hemodialysis allows an unrestricted diet D. Hemodialysis returns a balance to serum electrolytes

D. Hemodialysis returns a balance to serum electroyltes -Hemodialysis does not restore kidney function, it sustains the life of a client with kidney disease -Hemodialysis does not replace hormonal function of renal system due to tissue damage causing dysfunction of the RAAS -Hemodialysis does not allow an unrestricted diet, it requires a diet high in folate and more protein than redialysis restrictions allowed, and low in sodium, potassium, and phosphorus -The nurse should explain that hemodialysis restores electrolyte balance by removing excess sodium, potassium, fluids, and waste products, as well as restore acid-base balance

A nurse on a med-surg unit is admitting a client who has hepatitis B with ascites, Which of the following action should the nurse include in the plan of care? A. Initiate contact precautions B. Weigh the client weekly C. Measure abdominal girth 7.5 cm (3in) above the umbilicus D. Provide a high-calorie, high-carbohydrate diet

D. Provide a high-calorie, high-carbohydrate diet -Hepatitis B is transmitter via blood. Standard precautions are adequate -Daily wts are obtained to monitor fluid status -The client's abdominal girth is measured over the largest part of the abdomen, which will vary by client -The client who has hepatitis B should have a diet high in calories and carbohydrates

What is the area involved in superficial burns?

Damage of epidermis

What is the area involved in deep full thickness burns?

Damage to all layers of skin and extends into muscle, tendons, and bones

What is the area involved in deep partial thickness burns?

Damage to entire epidermis and deep into the dermis

What is the area involved in superficial partial thickness burns?

Damage to the entire epidermis and some parts of the dermis

Why would we administer nitrates to a patient with esophageal varices?

Decrease the hepatic venous pressure gradient

What is the pathophysiology of HHS?

Decreased insulin → decreased glucose entering the cells → increased glucose from the liver → hyperglycemia

What are the causes of hypovolemic shock?

Decreased intravascular fluid volume. -Caused by bleeding, dehydration, internal fluid shifts.

What is hypothyroidism?

Decreased levels of thyroid hormones that can affect all body function

What are the causes of cardiogenic shock?

Decreased myocardial contractility -Caused by MI or HF exacerbation

How does RAAS start?

Decreased perfusion to kidneys

What is the negative feedback system like for thyroid hormone?

Decreased serum thyroid hormones → anterior pituitary stimulates TSH production → TSH stimulates thyroid gland → thyroid gland produces T3 and T4

What are the causes of distributive shock?

Decreased vascukar tone

What is diabetes insipidus (DI)?

Deficiency of ADH

What does IV fluid type depend on when replacing in a patient with DI?

Depends on Na levels

Why is neomycin/metronidazole administered for someone with hepatic encephalopathy?

Destroys bacteria that produces ammonia, so ammonia is decreased

What is the pharmacologic support like for shock?

Determine which med for which aspect of CO (HR x SV = CO)

What is fetor hepaticus?

Distinctive breath odor (stool smelling breath from ketones)

How does the dosage of diuretics change?

Dosage increases as severity increases, except you would not want to give diuretics to a patient in end-stage renal disease

What is key to "avoid the sinking ship"?

Early identification

What increases the chance of survival of shock?

Early treatment

What is triglycerides like in chronic kidney disease?

Elevated (not sure why)

What is serum BUN like in chronic kidney disease?

Elevated bc kidneys cannot filter out

What is serum K like in chronic kidney disease?

Elevated bc kidneys cannot filter out

What is serum creatinine like in chronic kidney disease?

Elevated bc kidneys cannot filter out

What is serum phosphorus like in chronic kidney disease?

Elevated bc kidneys cannot filter out

What is a reproductive manifestation of chronic kidney failure?

Erectile dysfunction

Why is it better to look at BUN to evaluate hydration status over Cr in DKA?

Excess ketones can cause a falsely elevated Cr

What is hyperthyroidism?

Excessive secretion of thyroid hormones

How can peritonitis and infection occur in late cirrhosis?

Extra stagnant fluid (edema) around a bacteria filled area like a colon

What is MODS?

Failure of two or more organs so homeostasis cannot be sustained without support

What does hepatorenal failure occur in late cirrhosis?

Fluid back up from liver → fluid backs up all over body, including kidneys → decreased perfusion to kidneys → too much RAAS

When is medication used to increased HR in shock patients?

For progressive stage when HR is decreasing

What can 1 second of being submerged in 150 degree water cause?

Full thickness burns

How should calcium acetate be given?

Given with meals because the get the phosphorus from foods, binds to the phosphorus, and then gets rid of it

What is GFR?

Glomerular filtration rate; volume of fluid that filters into Bowman's capsule per unit time

What is glycogenolysis?

Glycogen to glucose

How does HHS develop in comparison to DKA?

HHS develops more gradually than DKA (pt can have vague symptoms for days/weeks)

What do AST and ALT ratios help distinguish?

Help distinguish between hepatitis and infections

Why might librium or ativan be prescribed to someone in cirrhosis?

Help prevent withdrawal symptoms

Why is heparin controversial?

Heparin will help prevent patient from using up clotting factors, but in order to stop the bleeding, your body needs to clot and heparin stops that

What is hyperglycemia?

High levels of glucose in the blood

What is normal serum cortisol like?

Higher in the morning and lower in the evening

What is used for hormone replacement in Addison's disease?

Hydrocortisone (solu-cortef), because in high doses it is very similar to cortisol and aldosterone

What causes the pulmonary symptoms in SIADH?

Hypervolemia

When are PRBCs given in shock?

If patient is hemorrhaging

When is insulin with dextrose indicated for a kidney failure patient?

If pt comes into hospital with acute exacerbation and potassium over 6, they can go into a metabolic acidosis with coma, so it is emergent to get potassium lowered and it can be done with insulin.

Why is it important to replace volume loss in a patient with bleeding esophageal varices?

If you don't replace, they can go into hypovolemic shock from blood oss

What causes hepatic encephalopathy in late cirrhosis?

Impaired metabolism

When is serum osmo usually used?

In conjunction with urine osmolality

Why do we need adequate IV access in shock patients?

In order to optimize preload and afterload

How is chronic kidney disease stages?

In terms of decreasing GFR and serum wastes until they end up in endstage

What can happen in DKA from the glucose level above 200 mg/dl?

Increased glucose level → osmotic diuresis (urinary losses of H2O, Na, K, Mg, Ca, and phosphorus) → hypovolemic shock (from dehydration) and lactic acid (from decreased perfusion)

What can the increased glucose level cause in HHS?

Increased glucose level (>200 mg/dl) → osmotic diuresis (urinary losses of H2O, Na, K, Mg, Ca, and phosphorus) → hypovolemic shock (from dehydration that tends to be more severe than in DKA) and lactic acidosis (from decreased perfusion)

What is azotemia?

Increased nitrogen waste

What is syndrome of inappropriate antidiuretic hormone (SIADH)?

Increased production of ADH

Why is urine osmolality low in DI?

Increased water loss in urine decreases osmolality

Why is serum osmolality high in DI?

Increased water loss in urine increases serum osmolality

What is the purpose of ADH?

Increases water reabsorption by kidney

What causes the neuro symptoms in SIADH?

Increasing cerebral edema → increasing ICP

What type of burn has an increased risk od death?

Inhalation

What happens when glucose levels remain elevated for prolonged periods of time?

Inhibits body's ability to fight infections

How does sclerotherapy help esophageal varices?

Injects sclerosing agent into vessels that causes them to shrink

Why does furosemide work so well at the ascending limb of Henle's look?

Instead of reabsorbing 25% of Na like it normally does, furosemide blocks it → Na stays in the filter → where Na is, H2O follows → more urine output (UOP)

What is the pathophysiology of DKA?

Insufficient insulin → decreased glucose entering the cells → breakdown of fats into fatty acids → liver ionizes fatty acids into ketones → increased glucose → hyperglycemia

What is the major hormone produced by the pancreas?

Insulin

Why is there no ketone formation in HHS?

Insulin levels tend to be sufficient enough to prevent ketone formation

Why is there rentention of aldosterone in portal hypertension?

Less perfusion to kidneys

What is the goal for blood sugar in critically ill patients?

Less than 180

What does ACTH regulate?

Levels of the cortisol

What is preferred more, sclerotherapy or ligating bands?

Ligating bands

What is the pathophysiology of hepatic encephalopathy?

Liver unable to convert urea for excretion → ammonia accumulates → ammonia crosses blood brain barrier → neuro symptoms

Where is the pancreas located?

Located in abdomen and is surrounded by stomach, small intestine, liver, small intestine, and gall bladder

What does balloon tamponade look like?

Looks like an NG tube

What is albumin levels like in live failure?

Low

What are Hgb and Hct levels like in chronic kidney disease?

Low because erythropoietin is produced by the kidneys, and when that is low (like in CKD), there is not as much production of RBC

What is the calcium level like in chronic kidney disease?

Low because the kidneys are retaining phosphorus (these two have to have an even relationship)

How is V/Q imbalance compensatory for shock?

Low perfusion to lungs → V>Q → increased RR

What is the goal of the compensatory stage?

Maintain perfusion to vital organs

What are the endocrine hormones like in a healthy physiological state?

Maintained at a relatively constant level

What would be seen in normal filtration?

Means you have urine output

What is osmolality?

Measure of the number of dissolved particles in a fluid

What is important to note about geriatric patients and the compensatory stage of shock?

Might not show increased HR necause of medications like beta blockers and calcium channel blockers since they slow down HR

What is an important nursing implication for patients who undergo surgical management for hyperthyroidism?

Monitor airway postop!

What turns yellow first in a patient with jaundice?

Mucous membranes, but we tend to notice the sclera of eyes and color of skin first

What is toxic multinodular goiter?

Multiple growths on thyroid gland

What is the most severe form of hypothyroidism?

Myxedema coma

Why would we want to restrict Na in a patient with nephrogenic DI?

Na restriction will enhance fluid reabsorption

What replaces necrotic cells in cirrhosis?

Necrotic cells replaced by nonfunctional scar tissue (remodels the liver)

What are the diagnostic findings of Cushing's syndrome?

Need 2/3 of these: -Serum cortisol NOT higher in the morning and lower in the evening -Urinary cortisol >120 mcg -Low-dose dexamethasone (decadron) suppression test showing cortisol level > 5mg/dl

What type of feedback system are most hormones regulated by?

Negative feedback system: as a hormone level increases, further production of that hormone will decrease (and vise versa)

What type of shock has decreased heart rate?

Neurogenic shock

What is important to remember about obtaining vital signs on a hemodialysis patient?

Never do BP in arm with a working fistula or graft because it occludes blood flow to that area it will occlude it and make it stop working!

Would we give milk of magnesium (MOM) to a patient in chronic kidney failure?

No we wouldn't, the magnesium is usually high already and that would raise it even more

Should you insert an NG tube in a patient who has known or suspected esophageal varices?

No! It is a sharp tube and can rip them open

Can a patient on a vasoconstrictor drip be on hemodialysis?

No, their body won't tolerate it

What is polycystic kidney disease?

Noncancerous cysts on kidneys that impairs function

What is the "oliguric phase" like when a pt is in nonoliguric ARF?

Normal urine output but retention of wastes

Is kidney transplantation a cure for kidney disease?

Not a cure, but is a life sustaining treatment

Where are the adrenal glands located?

On top of the kidneys

When should you give bicarb to a patient with DKA?

Only if pH is less than 7.0, and it is only used to raise it up to 7.1

What happens to bleeding times in liver failure when the liver cannot product clotting factors?

PT times go up

Besides a CT, how else can you determine if a liver is enlarged?

Palpation of RUQ

What formula do we use for fluid resuscitation?

Parkland : 4ml x kg x %TBSA (as a whole number) = 24 hour amount

What is the most definitive hepatic diagnostic test?

Percutaneous liver biopsy

Filtration Pressure Gradient

Pink = blood Yellow = kidney parts

What gland is considered the master gland of the endocrine system?

Pituitary gland

What is an important nursing implication for hyponatremic patients, like those in SIADH?

Place on seizure precautions!

What is the primary risk factor for esophageal varices?

Portal hypertension

What is the purpose of prolactin?

Prepares females for breast-feeding

What is the most common cause of AKI?

Prerenal (occurs in 60-70% of cases), but more specifically, sepsis

What do you give if the patient is hypotensive after fluid resuscitation?

Pressors: (phenylephrine, vasopressin, epinephrine, norepinephrine*-first line pressor)

What does silver sulfadiazine do?

Prevents infection

What are the prerenal causes of ARF/AKI?

Problem getting volume or perfusion to kidneys -Decreased vascular volume -OR, big surgeries, CABG, hemorrhage, burns, prolonged vomiting or diarrhea, excessive diuresis -CHF, MI, cardiac dysrhythmias -Renal artery stenosis -Septic shock, anaphylaxis -Decreased albumin, liver failure

Why do we give IV calcium gluconate?

Protect the heart because there could be dysrhythmias from potassium

What is nephrotic syndrome?

Protein in urine, but not blood

Why is hypernatremia seen in patients with DI?

Pt excreted so much water, so their serum sodium is more concentrated

How much blood flow does the thyroid receive compared to the liver?

Receives 5x as much blood flow compared to liver

What is the main function of insulin?

Regulate glucose

What is non-oliguric?

Renal failure even when output isnt low

What is the ABGs like in shock?

Respiratory alkalosis (early) → mixed acidosis → decreased LOC and respiratory acidosis

What does the endocrine system do?

Secretes hormones that regulate the bodies functions

What is the palmar method?

Separate method of measuring burn based on the palm size of the patient, the palm = 1%

What is severe sepsis?

Sepsis associated with organ dysfunction, hypoperfusion, or hypotension

What is the different between SIRS and sepsis?

Sepsis is SIRS with documented infection

What is septic shock?

Sepsis with refractory hypotension to appropriate reanimation and hypoperfusion manifestations

What should a patient's weight be like after dialysis?

Should be losing weight bc they lost all that fluid and waste

Why do we give post-op renal transplant patients immunosuppressants?

So they kidney can survive

Why can hepatic encephalopathy be challenging to recognize?

Sometimes hard to tell if pt is drunk or if its ammonia build up

What is transjugular intrahepatic portosystemic shunt (TIPS)?

Stent inserted via catheter to the portal vein to divert/reroute blood flow (so blood goes from liver to venous system)

What is the purpose of ACTH?

Stimulates adrenal cortical hormones

What is the purpose of growth hormone?

Stimulates bone and muscle growth

What is the purpose of TSH?

Stimulates thyroid hormones

What is glycogenesis?

Storage of glucose

What does elevated BUN suggest?

Suggests kidney disease

What is an example of a superficial burn?

Sunburn

What is a fasciotomy?

Surgical incision through fascia to relieve constricted muscle

What does the stage of shock depend on?

Sxs and severity/number of organs invovled

What would indicate that a patient isn't tolerating paracentesis?

Sxs of shock

How long does it take for the erthropoietin alfa injection to work?

Takes 2-4 weeks to work

What is the relationship between Na blocked from being reabsobed into the serum in the kidneys and the amount in the urine?

The more Na blocked from being reabsorbed into the serum in the kidneys, the more that stays in your urine, pulling water with it

What is the relationship between Na reabsorption and K wasting?

The more Na that is reabsorbed, the more K is wasted

What is the relationship between insulin and K?

The more insulin, the lower the serum K (bc it gets pulled into the cells)

What is Cushing's syndrome?

The result of excessive adrenocortical hormones

Why does stool turn clay-colored in jaundice?

The stool is in absence of bile, which gives it its normal color, since it is stuck in the skin

Why do we montior for clotting/bleeding during hemodialysis?

There is heparin in the line to make sure it is patent

What is the relationship between GFR and UOP?

They go in the same direction. More GFR will have more UOP, less GFR will have less OUP

Why would we give thiazide diuretics (like hydrochlorothiazide) to a patient with nephrogenic DI?

They may increase tubular sensitivity to ADH

What might need to be done if there are problems since a patients last hemodialysis run?

They may need to change hemodialysis timing or how much is being removed from them

What is the largest endocrine gland?

Thyroid

Why do we give post-op renal transplant patients aspirin?

To prevent clotting around the new kidney

Why would we administer non-selective beta blockers like propranolol to a patient with esophageal varices?

To prevent new bleeding by relaxing area

Why would we administer vasoconstrictors like vasopressin or octreotide to a patient with bleeding esophageal varices?

To stop current bleeding

What are esophageal varices?

Tortuous, dilated, blue veins occuring along the vertical axis of the esophagus

What is the medical management like for Cushing's syndrome?

Treat the underlying cause! -Tumor: ^Surgical removal or tumor ^Radiation therapy -Corticosteroids: ^Reduce or taper the medications

What is the progress of shock like?

Unpredictable

What is polyuria?

Urine output greather than 3000 ml/24 hours (can be seen in diuretic use and polyuria even in renal failure)

What is anuria?

Urine output less than 100 ml/24 hours

What is oliguria?

Urine output less than 400 ml/24 hr or <0.5 ml/kg/hr (30 ml/hr)

Why would a wound vac be used for a patient with burns?

Uses pressure to help close wounds and increase healing

What is the fluid restriction typically set for a patient in acute renal failure?

Usually 500-600ml more than yesterdays urine output

Where is the pain usually at in burns?

Usually in surrounding area (center area might not be painful due to deepness/nerve damage)

What is sodium like in chronic kidney disease?

Variable

What do epinephrine and norepinephrine do to the vessels?

Vasoconstrict

What is the bullseye concept of the zones of burn injury?

Want to protect the bullseye area to keep it from worsening

What should you watch for when a tumor causing Cushing's syndrome is surgically removed?

Watch for sxs of adrenal insufficiency (Addison's)

Why isn't biliary cirrhosis common in the US?

We do cholecystectomies

When does end stage kidney disease occur?

When 90% of functioning nephrons are destroyed and body not able to maintain homeostasis

When should we be more careful about fluid intake in kidney failure patients?

When GFR goes down

What are the causes of Addison's disease?

When adrenal glands are damaged and cannot product enough adrenocortical hormones (aldosterone, cortisol, sex hormones): -Surgical removal of adrenals -Autoimmune or idiopathic atrophy -Tuberculosis -Medications ^anticoagulants ^antibiotics ^corticosteroids