Exam II

Chronic kidney disease (CKD)

CKD- progressive, irreversible, loss of kidney function

risk factors: diabetes(poor glycemic control causes kidney damage), uncontrolled hypertension (perfusion issue), NSAID use/overuse, nephrotoxic substances, family history?

how does this occur:

FIVE stages:

1. GFR >90 mL/min: focus on prevention and risk factor management: control diabetes, htn, lifestyle mods, monitor kidney function

2. GFR 60-89 mL/min: focus on slowing progression, montior kidney function q6-12

3. GFR 30-59 mL/ min: continue to manage complications: Protein, Na, K restrictions, Monitor anemia, Assess Ca/ K balance, phosphate binders with meals, Monitor for bone disease, Monitor kidney function q3-6m

4. GFR 15-29 mL/ min: prepare for kidney replacement therapy, Strict diet: protein 0.6 g/kg, K 60- 70, Na 1-3g, Assess vitamin/ minerals, Monitor fluids, Dialysis education and planning

5. GFR <15 mL/ min: ESKD, kidney replacement therapy: Dialysis, Diet restrictions, Monitor dialysis complications, Vascular access care

clinical manifestations: decreased output, diluted urine, tremors(high magnesium), edema, htn, sob, uremic symtpoms: fatigue, nausea, anorexia, albuminuria

labs: potassium(increased), sodium(decreased then increased in end stage), magnesium(increased-tremors-can give calcium gluconate), phosphorus(originally increased then decreased); calcium(originally decreased then calcifies and increases), H/H (decreased)

urinalysis will show: proteinuria, hematuria(tea colored urine), foamy, high WBC

• sodium and fluid balance: hypernatremia, edema

• altered potassium excretion: cardiac dysrhythmias

• impaired metabolic waste elimination: metabolic acidosis, high

• altered calcium and phosphorus: decreased calcium and increased phosprous

• decreased production of erythropoietin: decreased RBC production- anemic(low o2, dizzy, headache, pale, sob)

diet: low sodium, low potassium

top priority: avoid NSAIDS, fluid restrictions, avoid processed foods and high sodium foods, check vascular access for bruit and thrill before hemodialysis

treatment: calcium acetate- high phosphorus,

hyperkalemia

risk factors: ckd, oliguria, anuria, k sparing meds

clinical manifestations: peaked t waves, cardiac dysrhythmias, muscle weakness, often asymptomatic until severe, fatigue, dyspnea

treatment: restrict intake of K to 60-70 mEq, avoid salt subs, ecg monitoring

C BIG K DROP

C-calcium gulconate

B-beta 2 agonist

I insulin

G glucose

K kayaxalate

D diuertics

dialysis

how to explain this to patient: CKD progressed to stage 5, kidneys don’t work properly and cant filter out waste from blood so this will do it for them and replace it.

what are the options: hemodialysis and peritoneal dialysis

what to expect: nutrition therapy and fluid restrictions, daily weights

hemodialysis

how often does the patient receive: 3 times a week for 3-4 hours

where can it be performed: center for it, hospital, some at prisons

what type of diet should a patient be on, foods to avoid: low sodium, low potassium, low protein, high carb

types of access a patient could have, which is long term and which is short term:

• AV fistula (surgical vein and artery together in forearm)- synthetic tube, first line to increase blood flow, cant use it right away(needs to mature first), permeant

• AV graft- synthetic tube placed between an artery and vein, permanent

• Central venous catheters: Inserted into subclavian, internal jugular, or femoral vein

• Subcutaneous devices: Surgically implanted ports with catheters in large central veins

• Temporary access requires longer treatment time (4-8 hours) due to smaller catheter lumens

complications: infection, equilibrium syndrome(nausea, vomiting, seizures, coma), cardiac events, low bp, hemorrhage, dizziness, weak, cramping

nursing assessment: full set of vitals before and afterwards, blood sugar, weight, changes in mental status, drowsiness, fatigue

peritoneal dialysis

how often is it received: every day for 8-10 hours

where is it performed: home- usually when sleeping

why does a patient receive this and not HD: if they couldn’t get a fistula or graft (access problems), when waiting for AV fistula to mature

different types of access: abdomen (surgically placed)

contraindications: recent abdominal surgery, excessive scaring in peritoneal region

complications, nursing interventions: peritonitis- infections of peritoneum or blood vessels in stomach- fluid will look cloudy (prevent by maintaining sterility when touching catheter)

nursing assessment: watch fluid may look cloudy if its peritonitis, pain level

peritonitis

complication of peritoneal dialysis

infection of peritoneum or blood vessels in stomach

fluid will look cloudy and painful

prevent this by maintain sterility

diagnostic- culture the fluid

fluid overload

commonly seen in kidney disease patients

edema, crackles, abdominal girth, overweight

worried most about: pneumonia

indicated: call the doctor, obtain CBC and BNP, request order for chest x ray, obtain wound culture from infected dialysis site, obtain second IV access

nonindicated: blood sugar, extra fluids, request order for creatine clearance test(already know he has kidney disease), provide education to PD care(will do this eventually but not in an emergency situation)

failure to rescue

hyperkalemia can quickly lead to further damage or patient death

failure to recognize early cues

reasons why signs of inflammation occur

heat/redness- due to increased blood flow to site of inflammation

swelling-accumulation of fluid and cells

acute inflammation

predominant cell- neutrophil

time course- rapid onset

nature of response- physiologic

tissue dmaage- usually mild and resolves wquickly

chonric inflammation

macrophage and t lymphocyte

slow onset, long lived

pathologic

often severe and progressive

what labs indicate the presence of inflammation

CBC-WBC

c reactive protein

esr

which type of food would the nurse teach a patient with chrons disease to avoid

wheat

which medication would the nurse amdinister iv to a pateint with chrons disease who reports numbness, tingling, and painful muscle contractions and whose deep tendon reflexes are hyperactive on examination

magnesium sulfate

which patient goal wiudl the nurse establish when providing care for a pateint admitted with hypocalcemia secondary to chrons disease and sevre diahrea

negaive chvostek sign

ulcerative colitis diet

flaxseeds

pateit with ulcerative colitis is rpecsirbed sulfasalazine and corticosteriod therapy, whihc change would the nurse expect in the patients medication regimen would occur

corticosteriods would eb tapered

which nursing action would help minimize a pateients discomfort when experiecing an exacerbation of ulcerative colitis

restricting lactose containing foods, rest in bed(dont walk)

which potential complication is associated with chrons disease

fistulas, osteoporosis, malabsorption, abscess formation

chrons disease

can involve any part of the gi tract, often affects the colon and terminal ileum

signs: RLQ abdominal pain, chronic diarrhea, weight loss, steaturia(fatty stools), fatigue,

have an increase risk for fistula formation that can cause bladder infections, dehydration

malabsorption risk- usually vitamin b12 deficiency anemia, low potassium, low albumin, low protein

diagnostics- colonoscopy with multiple biopsies of colon and terminal ileum, inflammation may have a skip area with normal appearing mucosa. small bowel may show cobblestone appearance. capsule endoscopy may help when traditional endoscopy cannot visualize the entire small intestine

labs: elevated crp and esr, low albumin(malabsorption), low Hb(anemia), low potassium

complications: fistulas(abnormal tunnel forms between the bowel and another structure: drainage, fever, pain, infection skin irritation) , strictures(chronic inflammation and scaring can narrow the bowel lumen: cramping, pain, distention, n/v) may be present in urinary tract- SIGN IS TAN COLORED URINE, perforation(severe abdominal pain, rigid board like adomen, high hr, low bp, fever), abscesses: localized pocket of infection may form in the bowel wall or surrounding tissue: fever, localized abdominal pain, tenderness, leukocytosis; could need antibiotics, drainage, or surgery

treatment: D5 half normal saline, infliximab, methyl prednisone, loperamide, not treated with surgery only complications are

PRIORITY CONCEPT IS NUTRITION

nursing considerations: assess stool, don’t restrict fluid, monitor weight, don’t limit meals, daily calorie count, low fiber/low fat diet/high protein,

effective treatment plan: monitor bmp, increase in albumin, decrease in stool frequency, increase in weight, decrease in crp(FIRST) and esr, normal colored urine

ulcerative colitis

colon issue

signs/symptoms: bloody loose stools, abdominal cramping, fatigue, presence of melena in the stool, intolerance to milk/milk products, use of NSAIDS for pain, low hr, sudden urge to have bowel movement(tenesmus), weakness, dehydration

more blood loss- iron deficiency anemia

diagnostics: every 10 years colonoscopy biopsy(will show inflamed hemorrhagic mucosa, ulcerations, and irregular mucosa), stool culture rules out infection as cause

labs: low iron, low Hb, low albumin(hypoalbuminemia), low serum potassium, elevated esr

treatment: sulfasalazine, methyl prednisone, diphenoxylate, surgery(laparoscopic surgery), ileostomy placed in small intestine, colostomy in colon

nursing consideration: monitor stool, don’t hold sulfanzine for a systolic bp below 100, dont give NSAIDS, monitor bmp, don’t encourage ambulation, get bedside commode, monitor if no stool is passed

education: preop, colostomy care(monitor skin, stool will form 2-3 days postop, avoid caffeine/spicy/gassy foods/nuts/veggies with skin/rice/tomato’s/corn/peas, empty when halfway full, change pouch every 3-7 days, loose stool is normal for ileostomy, stoma is red and moist)

complications: perforation(toxic megacolon—>sepsis/hypovolemic shock)-(hr increase, bp decrease, absent bowel sounds, distended abdomen-NOTIFY RRT)

continuous inflammation

first line medication treatment for ulcerative colitis

sulfasalazine

signs of low potassium

heart palpitations

dysrythmias

what is priority before administering infliximab

screen for TB

lab test to monitor when taking sulfasalazine

cbc- can cause blood disorder and anemia

liver fucntion

renal fucntion

which complciations are assoicated with crohns disease

fistula formation

bowel obstruction

malabsportion

perforation

ulcerative colitis vs Crohn’s

UC: confined to rectum and colon(continuous), bleeding more likely, more at risk for colon cancer, diarrhea with puss and blood, could be asymptomatic, cause is unknown, inflammation, edema, fluid and electrolyte loss, malnutrition, iron deficiency anemia

Crohn’s: whole gi tract, noncontinuous, all the layers of the intestinal wall, cobblestone appearance on colonoscopy that stop body from absorption nutrients, fistulas, obstruction, fissures, abbesses, vitamin b12 anemia

pulmonary embolism

continuous pulse ox, montior vitals, lung sounds, cardiac status every 1-2 hours, assess for dyspnea, dysrythmias, crackles, cyanosis

anticoagulants and monitor labs

signs: sudden sob, pleuritic chest pain(sharp/ stabbing that intesifies when you cough), hemoptysis(coughing up blood), anxiety, restlessness, pain raidating to shoulder

nursing interventions: oxygen via 100% rebreather, anticogaualtion, monitor PTT/INR, asses repsirtory status, call RRT FIRST, ecg, abg(alkolosis), d dimer, heparin drip

assessment findings: PESTO (pleuritic chest pain, elevated rr, sob, tahcycardia, o2 decreased)

risk factors: FAT BAT(fracture/recent surgery, a fib, travel, birth control, active cancer, tobacco use

prveention/care: HAD CLOTS (hydration, ambulation, dvt prevention, compression devices, leg exercises, obsevre for sudden chest pain, teach antigoaluation safety, stop smoking

b12 deficency anemia

signs/ symptoms: fatigue, pale, skin, paresthsia of the ahnds and feet, glossitis(beefy red tongue), difficulty with balance, decreased HGB, tachycardia

treatment: b12 injections, b12 nasal/oral, animal proteins, fish, eggs, nuts, dairy, beans, citrus, leafy greens, VEGANS/VEGETARIAN: fortified cereal, cheese, supplement, synthetic meat, seafood

iron defenicey anemia

signs: fatigue, pale skin, fissures in the corner of the mouth, decreased hgb, tachycardia, low ferritin(10-15)

treatment: ferrous sulfate, ferumoxytol, iron dextran, red meat, organ meat, egg yolks, kidney beans, leafy greens, raisins, iron and vitamin c

impauired gas exhcnage early manifestations and late manifestations

early: tahcypnea, tachycardia, restlessness, anxiety, mild dyspnea on exertion, pale skin/mucous membranes

late:sevre dyspnea at rest, cyanosis, confuasion, dysrythmias, hypotension, syncope, distended neck veins, crackles in lungs, cardaic arrest/ shock

a client with pancreatitis should avoid what becuase it can tirgger pancreatic stu=imulation

fatty/fried foods, alcohol

biliary system

liver: makes bile

gallbladder: stores and concentrates the bile

pancreas: exocrine: secretes hormones in the blood stream (insulin/ glucagon) endocrine: helps blood sugar levels

whihc symtpom of postcholecystectomy syndrome shiudl the pateitn report

vomitig, diarrhea, epigastric pain

if a patient wqith acute pancreatitis isnt able to eat fter 48 hours what shoudl the nurse do

j tube feedings

what would the nruse montior to ebulate efefctiveness of pancreatic enzyme tehrapy

consistiency and number of stols

cholecystitis

risk factors: obesity, hyperlipidemia, female, pregnancy, rapid weight loss(body is more likely to develop stones), high fat diet, estrogen therapy(increases cholesterol saturation in the bile)

signs: RUQ epigastric pain that radiates to right shoulder, vomiting, diarrhea, pain after eating fried foods, nausea, rebound tenderness, dehydrated

PRIORITY CONCEPT: pain

expected orders: npo, fluids, pain relief(opioid for severe and ketorlac for moderate), nausea relief (monitor tele), ultrasound, HIDA csan

treatment: cholecystectomy(gallbladder removal:open/closed; carbon dioxide gas inflates abdomen, laparoscope is inserted through port, images transmitted to monitor, surgeon grasps gallbladder and clips off main arteries, drops into specimen bag, port valve left in place to left carbon dioxide escape, if there are complications they cut open more)

after surgery what is expected and whats concerning:

expected: mild shoulder pain, small amount of serosanguinous drainage, wbc slightly elevated

unexpected: fever, increasing abdominal distention

education: shoulder pain after surgery from carbon dioxide(encourage ambulation, heat in painful area), typically same day surgery, don’t soak in tub, ice on and off for 20 min for stomach/incisional pain, post cholceectomy syndrome (avoid fatty foods bc you have intolerance) low fat diet(can still develop gallstones even if gallbladder is out), ambulate, incentive spirometry, no ng tube needed, no pca pump, iv fludis and clear liquids until po is tolerated, no drains, can return to activies in a week, shower day after surgery, surgical glue will fall of naturally,

notify surgeon if vomiting, returning pain, signs of infection, opening of incision, delayed wound healing, fever

pancreatitis

risk afctors: alchol use, gallstones, hypertriglyceridemia

signs: epigastric pain radiating to back, pain worse when supine, elevated alt, amylase, wbc, lipase, glucose, low calcium,

secreting enzymes too early that results in auto digestion and leads to fibrosis of the pancreas

ask: when did the pain start( after fatty foods/when drinking), is it worse when supine, rating, location, characetristics, what makes it better/worse, radiating?, history of cholecystitis(gallstones and ercp(takes out gallstones) put them at higher risk)

assess: respiratory function, may find diminished breath sounds, grey/blue discoloration around umbilicus (putting pressure on it), bowel sounds(absence can show paralytic ileus), pancreatcileus(gaurding reboudn tnederness)

PRIORITY: reduce pancreatic stimualtion by decreasing gi motility, PAIN DECREASE

interventions: npo, possible ng tube, administer iv fluids, montior output hourly(shows they have proer perfusion), administer pain meds

education: small frequent meals(moderate to high in carbs, high in protein, low fat, bland/no spices), npo to decrease pancreatic enzyme secretion, respiratory distress syndrome(could happen in aucte and chornic)

acute expected/worsening condition:

expected: elevated lipase, epigatsric pain raidating to back, hyperglycemia

worsening: cullen sign(grey blue of stomach), hypotension, hypocalcemia

if worsening signs are showing hypovolemic shock may be happening (low bp, high hr, high rr, low o2, low urine output)

a pateint has just undergone a laproscopic cholesectomy is reporting shoukder pain . what si the cuase of this pain

carbon dixoide gas

barium enema

indications: to detect IBS (Crohn’s or ulcerative colitis) shows polyps, tumors, strictures, ulcers. tube that goes in rectum and contrast goes through

prep: npo, take laxatives the day before the test (magnesium sulfate), cleansing enema

recovery: monitor stool color

patient teaching: hydrate, take laxatives because the barium might cause constipation

colonoscopy

indications: IBS biospy (to confirm or assess for colorectal cancer). get biopsy to remove polyp, shows entire large bowel

prep: npo and bowel cleansing for 8 hours, clear/liquid diet for 1-3 days before, drink electrolytes, avoid red/purple/orange since it looks like blood

recovery:

patient teaching: signs of bowel perforation (fatigue bleeding)

HIDA scan

indications: to detect cholecystitis. flow in biliary system, to see if gallstones are blocking anything. radioactive tracker that they inject into the veins

prep: npo 4-6 hours before, no opioids since it slows down everything

recovery: assess for allergies

patient teaching:

ERCP

indications: visualize liver, gallbladder, pancreatic duct. use contrast dye. can be diagnostic or treatment (can remove gallstones).

prep: npo for 6-8 hours

recovery: can cause perforation, hypovolemic shock, abdominal pain and gas

patient teaching: can cause pancreatitis

which statement is true abotu the differences in the anataomy and physiology between infants and older children. infants have

a porportionally larger tongue than older children

anatomy in inafnts that cause difficulty in oxygenation

larger tongue

more narrow trachea

immature airway, more floppy

mostly breathe through their nose(tachypnea, tachycardia)-suction mucus

get tired quicker-dont have high stamina

immature immune system

fewer and smaller alveoli

moire mucous memebrane cewlls

at what age may a child with sickle cell disease first experience dactylitis

6 months

when youre first bone you have fetal hemoglobin at 5-6 months it converts to hemoglobin a which is what normal people ahve if you dont have sickle cell

dactylitis

inflammation/swelling of fingers or toes as a result or acute sickle cell

6 months

treatments: would give anti-inflammatory (ketorolac), penicillin everyday, give opioid as if they had a VOE in arm/leg, IV fluids

what would you not do with acute chest syndrome

nebulized racemic epinephrine

acute chest syndrome

chest/back pain, fever

kinda like pneumonia for specifically sickle cell patients

do cbc, wbc may be high so it requires antibiotics

splenic sequestrations

blood pooling into spleen(protects against infection)

hgb will be low because blood is not circulating anymore

lethargic, irrtable, low hgb

palpate spleen

sickle cell

Two kinds:

-acute- CVA (stroke), acute chest syndrome, splenic sequestration, Priapism, Bacteremia(bacteria in the bloodstream), VOE/VOC(when rigid, sickle-shaped rbc block small blood vessels, restricting blood flow and causing sudden, severe, and potentially damaging tissue ischemia and pain), Dactylitis(swelling)

-chronic- low hemoglobin, tachycardic, Hyperbilirubinemia (dying rbc), HgbS, Elevated reticulocyte count (bone marrow is working overtime to produce immature rbc-if its normal it would be a sign the body isn’t making enough rbc), Elevated sedimentation rate (rbc settle faster than normal)

bone marrow makes- wbc, rbc, platlets

considerations: avoid steroids

treatment- stem cell transplant,

which is included in the assessment of an infants respiratoryv status

retractions

which is considered a risk factor for respiratory syncytial (RSV)

formula fed babies and preemies

male at higher risk than females

obtaining general history for oxygenation RSV

start narrow to broad

questions: what symptoms, when did it start, risk factors/history, vaccinations, who lives at home, siblings, daycare, etc, exposed to smoke, diet, family history(asthma), travel, gestational age, apgar, nicu, elimination(do they have less or the usual amount of dirty diapers)

assessment-retractions, o2, rr

virus can cause what

bronchiolitis (lower airways)

rsv, flue, covid, metapneumo—> cough, rhinorrhea, fever, wob, dehydration

larygngotracheobronchitis LBT

signs: barky cough/seal like cough, retractions, low grade fever, tachycardia, high rr, stridor, hypoxemia, stridor,

upper airway problem

gradual onset, pulse ox

interventions: steam to open airway, sit upright, blast of cold air, monitor

treatment- racemic epinephrine , dexamethasone

epiglottitis

sudden onset, hypoxemia, stridor, difficulty swallowing, intubate, tripod position, high fever

no pulse ox when they come in bc its a medical emergency

treatment- antibiotics