Ill Exam 4 (renal, stroke)

nitrofurantoin / Macrodantin

-urinary tract anti-infective

-50-100 mg 2-3x/day for 7 days

-AEs: N/V, anorexia, HA, drowsiness, dizziness, brown urine, muscle weakness, tingling, numbness

—teach pt about urine color change!

-avoid antacids (they decrease absorption)

-nursing: increase fluid and fiber intake

UTI*

-risk fx: pregnancy, wet swimsuits, hot tubs, elderly, Foley, women, stool incontinence

-can be anywhere in urinary tract

-usually d/t E. coli

-dx: UA (nitrites, WBC, leukocyte esterase [pus]), urine culture

-tx:

—antimicrobials: often Bactrim (better than Macrodantin b/c cheaper and only 2x/day)

—pyridium: decreases pain (AE: red or orange urine)

—increase fluid intake (8-10 cups per day)

—teach pt: avoid baths, wipe front to back, void after intercourse, avoid perfumes near perineum, only use mild soap and water on perineum

acute pyelonephritis*

-often from lower UTI

-dx: UA, urine culture, blood culture, CBC (high WBC & shift to the left)

—US: find causes or complications

-tx: IV ATBx then oral ATBx (14-21 days), antipyretics

—carefully monitor BP (hTN indicates shock)

complication of UTI*

urosepsis: life-threatening bloodstream infection

—S/S: fever, chills, N/V

—dx: CMP (high BUN & creatinine), CBC (high WBC), high CRP, high ESR

—tx: IV ATBx

S/S of UTI by location*

-cystitis: suprapubic pain, burning, hesitancy, intermittency, dribbling, retention, dysuria, frequency, urgency, incontinence, nocturia, hematuria, N/V, foul smell, diarrhea; confusion in elderly

-pyelonephritis: cystitis S/S, fever, chills, flank pain, costoverterbal tenderness

acute post-streptococcal glomerulonephritis*

-d/t Ab attacking strep Ag → immune complexes deposit in glomeruli → autoAb formation → inflammation → increased permeability & pore size in glomeruli → loss of substances in urine + urine retention

-develops 2-3 weeks after strep infection

—ask pt if they have a recent hx of sore throat or fever

-S/S: proteinuria, hematuria, oliguria, tea-colored urine, periorbital/facial edema, HTN, weight gain, flank pain

-dx: UA (protein, RBCs), low GFR

-tx: rest (till urine is normal), sodium/fluid restriction, possible protein restriction, ATBx, antihypertensives

chronic glomerulonephritis*

-d/t: unknown, autoimmune disorder

-insidious onset

-causes progressive destruction of tubules and glomeruli → scarring → function loss

-S/S: HTN, fatigue, weight (loss?), pulmonary edema → SOB w/ exertion, edema, toxins → confusion, uremic frost, anemia

-leads to KF & ESRD

—need dialysis or transplant

-dx: UA (protein & RBCs), high BUN and creatinine, low GFR

—BUN is from protein catabolism, creatinine is from skeletal muscles

—creatinine is the best indicator of acute kidney problems

nephrotic syndrome

-glomeruli are excessively permeable to plasma proteins → proteinuria

—lose albumin → low OP → edema (ascites, anasarka)

—lose Ig → infection risk

—lose anticoagulant proteins → DVT & PE risk

-no hematuria

-hyperlipidemia (liver’s attempt to replace proteins)

-d/t DM, SLE, neoplasms, anaphylaxis, meds (e.g. NSAIDs)

tx nephrotic syndrome

-sodium restriction (2000 mg/day)

-low to moderate protein intake

-small frequent meals (anorexia d/t ascites)

-daily weights, strict I&O, measure abdominal girth

-skin care

-avoid NSAIDs

-meds

—steroids

—Epogen (EPO)

—anticoagulants

urinary calculi

-S/S: abdominal or flank pain, testicular or labial pain, hematuria, oliguria, N/V, diaphoresis, pallor, tachycardia

—renal colic: pain from stone stretching & dilating ureters and causing spasms

-risk fx: personal or family hx, gout, hypercalcemia, sedentary, diet, low fluid intake

care for calculi

-dx: UA, CT, cystoscopy

—IVP (if no hx of KF: involves injecting IV contrast, which is filtered by kidneys)

—assess stone for makeup (educate pt to reduce intake of ingredient to prevent future stones)

—hematuria indicates infection

-tx: opioid analgesics, ATBx if d/t infection, IVF, strain urine, Flomax or Hytrin (relax ureters)

—if stone does not pass on its own (>4 mm): stent, cystoscopy, ESWL + stent (hematuria common afterwards, but may give ATBx)

—teach: (during and after stone) 3 L fluid per day; avoid sodium; exercise, modify diet based on stone analysis

foods to avoid during and after stones

-oxalate: spinach, rhubarb, cocoa, beets, pecans, peanuts, Worcestershire sauce, dark sodas, caffeine, tea

-purine / uric acid: organ meats, fish, sardines, venison, goose

-calcium: green leafies, dairy, sardines, salmon

-cysteine: none (d/t genetic defect)

polycystic kidney disease

-autosomal dominant genetic

-kidneys filled with large, thin-walled cysts that compress and destroy tissue → KF → ESRD

-S/S onset is 30-40 years old

-S/S: HTN, hematuria, chronic pain in back/flank/abdomen

—palpably enlarged kidneys

-causes liver cysts, abnormal heart valves, aneurysm, diverticulosis, UTIs

-dx: US

-tx: nephrectomy + transplant (only cure)

—do genetic counseling

kidney CA

-usually renal cell carcinoma

-risk fx: male, obese, HTN, asbestos, smoking

-S/S: flank pain, palpable mass, weight loss, HTN, anemia, hematuria

-metastasizes to lungs, liver, long bones

-dx: CT, US, biopsy, KUB

-stages:

—I: in kidney, <7 cm

—II: peri-renal fat

—III: renal vein or IVC or lymph nodes

—IV: metastasis

tx renal CA

-chemo, radiation (often CA is resistant)

-radical nephrectomy: remove kidney, adrenal gland, fascia, part of ureter, draining lymph nodes

—post-op: I&Os, daily weights, TCDB + IS w/ splint

bladder CA

-risk fx: calculi, UTIs, smoking, Foley, radiation to area

-S/S: hematuria (no pain)

-usually do not invade bladder wall

-dx: UA, cytology, CT, US, MRI, cystoscopy w/ biopsy

-tx:

—radiation

—chemo

• e.g. intravesical therapy, via catheter: insert chemo, clamp cath and leave in for 2 hours (turn pt q15min)

—fulguration / electrocautery: laser photocoagulation

• post-op: increase fluids, avoid alcohol and straining; urine will be pink

—transurethral resection; or partial or total cystectomy

• need urinary diversion for total

catheters

-ureteral

—via urethra or surgical incision

—prevent edema → obstruction

-suprapubic

—through abdominal wall into bladder

—short or long term

-nephrostomy tubes

nephrostomy

—directly into kidney

—tx hydronephrosis

—assess for kinking or compression; NEVER clamp

—may irrigate (sterile) w/ 5 mL NS at a time

—post-op:

• TCDB & IS w/ splinting, splint

• watch for paralytic ileus (keep pt NPO until return of bowel sounds)

• muscles will ache post-op

• check & document UO q1hr

urinary diversion

-types

—continent

• anastomosis created: ureters connected to abdominal wall via ileum, stoma created

• intra-abdominal urinary reservoir/pouch created → no involuntary leakeage

• pt needs to self-cath q4-6hr

—incontinent (ileal conduit)

• similar process to continent

• constant urine flow → need bag (risk of skin breakdown)

-consult enterostomal therapist for stoma care

chronic kidney disease

-affects EVERY body system

-kidneys malfunction → waste and fluid and electrolyte retention

-causes uremia = creatinine and BUN increase → S/S

-causes decreased GFR and creatinine clearance

—GFR <15 mL/min → uremia

-S/S: none early or maybe polyuria, then oliguria, then anuria

—also HA, edema, HTN, weakness, fatigue, N/V, anorexia, itch, brittle hair, constipation (AE of iron supplement for anemia)

effects of CKD

-F&E: hyperkalemia, low vitamin D → hypocalcemia, hypermagnesemia, metabolic acidosis (H+ retention)

-CVS: anemia, thrombocytopenia, leukopenia, HF, CVA, MI, dysrhyhtmias (d/t high K+)

-resp: dyspnea, Kussmaul’s (compensatory for pH), pulmonary edema, pleural effusion

-neuro: encephalopathy (d/t toxins), peripheral neuropathies (restless legs, sensation of bugs crawling on skin, burning), depression

-GI: mucosal ulcers, metallic taste in mouth (toxins)

-skin: jaundice, uremic frost

-reproductive: infertility, ED, low libido

-skeletal: osteoporosis → fractures (d/t low Ca2+ → high PTH → osteoclasts activated)

stages of CKD

1. minimal kidney damage, low-normal GFR, high-normal BUN/creatinine

2. mild kidney damage with mild decrease in GFR

3. moderate damage w/ moderate decrease

4. severe

5. kidney failure w/ no GFR

care for CKD*

-dx

—24-hr urine collection (to test creatinine clearance, also proteinuria)

• save EVERY void for a whole day, refridgerate

• Foley: keep bag in bucket of ice

—KUB, kidney biopsy

-tx

—sodium restriction (2000 mg/day)

—restrict fluid, K+, protein

—restrict phosphorous to <1000 mg/d (helps increase calcium) (e.g. green leafies, meat, dairy)

—avoid meds w/ magnesium

meds for CKD

-combo to tx hyperkalemia:

—IV regular insulin (moves K+ into cell)

—IV glucose (to maintain BGM)

—10% calcium gluconate (aids transport across cell membrane)

-Kayexalate to tx hyperkalemia (AE: diarrhea)

-antihypertensives: ACE, ARBs, CCBs (goal = <130/80)

—maybe diuretics early on

-iron supplement and Epogen for anemia

-vitamin D supplement

-statins to tx hyperlipidemia (occurs b/c of compensation for proteinuria)

—contra: dialysis

*caution w/ meds processed by kidneys (lower dose, decrease frequency, etc)

dialysis*

-rids the body of excess fluid and electrolytes, maintains pH, eliminates waste

-pt must go several times per wk

-types:

—hemodialysis: blood is removed from body, filtered via dialyzer, and returned

• needed when GFR <15

• risk for hep B & C

—peritoneal: catheter inserted through peritoneum, solution pumped in, allowed to sit, and then drained

• often use dextrose

• pumped for 10 mins, sit (“dwell”) for 15 mins to 8 hrs, drained for 15 mins

• risk of herniation, pulmonary problems (elevate HOB), peritonitis (S/S: cloudy fluid from drain)

-before/after: weigh pt, VS, check labs

hemodialysis is via…*

-arteriovenous fistula

—may use AB graft

—allows vessel to increase in diameter over time and flow to be rapid (“fistula maturation”)

—assess patency by palpating thrill pulse and auscultating bruit

—assess neurovascular distal (signs of low perfusion: assess, then call HCP!)

—no tight clothing, BPs, blood draws, etc on limb; no heavy lifting; do not sleep on the arm

—hand exercises help promote fistula maturation

-central line

stroke*

-lack of perfusion to brain d/t ischemia or hemorrhage

-causes impaired movement, sensation, and/or emotions

-1/3 of stroke patients die w/in a year

-risk fx: elderly, fam hx, HTN, CVD, DM, smoking, hyperlipidemia, metabolic syndrome, obesity, sedentary, poor diet, drugs, cocaine, alcohol

—also A-fib (blood pools in atria and clots)

• these pt need to be on a blood thinner!

—reduce risk by keeping SBP <140

—*similar to CAD

-types

—TIA = transient dysfunction of focal brain, spinal cord, or retina; w/o acute infarction of brain (S/S last <1 hr)

• pt still needs to go to ER; may progress to CVA

—CVA: ischemic (thrombotic or embolic) or hemorrhagic

ischemic CVA*

-d/t inadequate blood flow to brain from artery occlusion

-types

—thrombotic: blood clot forms in cerebral artery

• no LOC in first 24 hr, progresses during first 72 hr

• TIAs common beforehand

• often d/t atherosclerosis in cerebral arteries, also HTN or DM

—embolic: blood clot travels from another location

• rapid severe S/S

• may be temporary

• recurrence likely

• commonly originates in heart: often d/t A-fib, MI, IE, prosthetic valve

• may be fat emboli from fracture

hemorrhagic CVA*

-d/t bleeding into brain, subarachnoid, or ventricles → pressure on brain and other vessels

—intracerebral: vessel w/in brain ruptures, often d/t HTN

• may also be d/t vessel malformations, coagulation problems, thrombolytics or anticoagulants, trauma, tumor, aneurysm

• often during activity

• progresses for hours; causes neuro deficits, HA, N/V, decreased LOC, HTN, seizures, stiff neck

• poor prognosis, esp if comatose

—subarachnoid

• d/t saccular or berry aneurysm, often in circle of Willis

• S/S: “worst HA of my life”

-tx by surgically clipping or coiling aneurysm

stroke S/S*

-altered personality, affect, sensation, perception, or communication

-motor: impaired mobility, respiratory function, swallowing, speech, gag reflex, voluntary movement, reflexes

—initial period of flaccidity for days to weeks, followed by spasticity

-also causes temporary problems with urinary and bowel elimination

other stroke S/S*

-communication: dysphasia or aphasia, dysarthria

-cognitive: uncontrolled emotional responses, impaired memory or judgment

-spatial-perceptual: incorrect perception of self and illness, erroneous perception of self in space, inability to recognize objects, inability to follow commands

—visual: homonymous hemianopsia, diplopia, ptosis, loss of corneal reflex

R vs L stroke S/S*

-R: left hemiplegia, spatial-perceptual deficits, denying problems, short attention span, impulsivity, impaired judgment and concept of time

-L: right hemiplegia, impaired speech, caution, anxiety, depression, impaired language and math comprehension

dx stroke*

-*need to confirm presence of stroke and find cause

-CT STAT !!!

—shows hemorrhage, not ischemia (till after 24 hr)

-MRI/MRA, angiography, Doppler US

—do stat after CT to show ischemia

-EKG, CXR, cardiac enzymes, echo, Holter monitor

—done later, shows A-fib

-ask pt what time S/S started

-neuro assessment (S/S worsen in first 24-48 hr)

-NIH stroke scale (11 questions/assessments)

—high value indicates presence of a stroke; higher score = worse stroke

stroke core measures*

determined by CMS and TJC

-must assess time of S/S onset and plan tx accordingly

-must get IV in w/in a certain time period

-must do a CT, etc w/in a certain time period

ischemic stroke tx*

-manage ABCs

-antipyretics, antihypertensives

—slight HTN is better than hTN

-control F&E, hydrate to maintain perfusion

—may need Na+

—avoid glucose

-decrease IICP: (peaks at 72 hr) elevate HOB, align head and neck, avoid hip flexion, seizure precautions

-surgery to place stent

meds for ischemic stroke*

-IVP, then IV inf recombinant tissue plasminogen activator (tPA)

—clot buster

—contra: elderly, bleed risk, recent surgery or head trauma

• need to do tPA screen first to determine if we can administer

• do coag panel and BGM before (hypoglycemia mimics CVA S/S), possibly NGT, 2+ IVs (large G)

—give w/in 3-4.5 hr of S/S onset

-325 mg aspirin

—give after 24 hr, before 48 hr

—may continue long term

-clopidogrel, warfarin, apixaban, etc

—after pt has stabilized

—may continue long term

hemorrhagic stroke tx*

-antihypertensives

—keep SBP around 140 (<160, but not too low)

-anticonvulsants

-surgery to clip or coil aneurysms

stroke rehab*

begins after pt is stable for 24 hr

-pt needs to be NPO (dysphagia → aspiration risk) until ST assessment & swallow study

-PT, OT !!! (3 hr QD)

-pt may need to go to rehab facility

-educate pt on modifiable risk fx

-pt may be placed on long-term anticoagulants, statins, antihypertensives, anti-DM, etc