Iggy Chapter 60, 63, 53, 54, 51, 52, 55 (pp. 204-1209)
Manifestations of renal insufficiency
decreased urine output
fluid retention
edema in the lower extremities
shortness of breath
fatigue
proteinuria
disturbances in fluid and electrolyte balance
disturbances in acid-base balance
buildup of nitrogen based waste in the urine
loss of kidney hormone function
Regulatory functions of the kidney
Glomerular filtration- first process in urine formation, filters blood and pulls water, electrolytes, and small particles
kidneys self regulate their blood pressure and blood flow so this is constant
increased or decreased depending on blood pressure and blood flow
Tubular reabsorption- second process in urine formation, most water, electrolytes, and small particles are returned to the blood
kidneys vary the volume or concentration of urine to help regulate fluid and electrolyte balance regardless of fluid intake
Tubular secretion- third process or urine formation, allows substances to move from the blood into the urine
potassium and hydrogen ions are moved from the blood to the urine to maintain fluid and electrolyte balance and acid-base balance
Hormonal functions of the kidney
Renin- assists in blood pressure control
released when there is a decrease in blood flow, blood volume, or blood pressure through the renal arterioles, or there is too little sodium in kidney blood
causes the production of angiotensin II which increases systemic blood pressure
when blood flow to the kidney is reduced, it prevents fluid loss and maintains circulating blood volume
Prostaglandins- help regulate glomerular filtration, kidney vascular resistance, and renin production
increase sodium and water excretion
Erythropoietin- produced and released in response to decreased oxygen in the kidney’s blood supply
triggers RBC production in the bone marrow
Vitamin D- converted to active form in the kidneys
activated vitamin D is needed to absorb calcium and regulate calcium balance
CT scans purpose
to measure kidney size
to evaluate contour to assess for injury, masses, or obstruction in kidneys or the urinary tract
assess renal blood flow
Concerns with using contrast dye with CT scans
when contrast is used, ensure that there is sufficient oral or IV intake to dilute and excrete the contrast media
it is potentially kidney damaging (nephrotoxic)
highest risk for older adults, dehydration, pre-existing CKD, diabetes, heart failure, current hypotension
those taking metformin should be temporarily discontinued before receiving contrast
Bladder scans
noninvasive method of estimating bladder volume
used to screen for postvoid residual volumes
determine the need for intermittent catheterization
before scanning select male or female icon
Laboratory tests and kidney function
serum creatinine- no other condition besides kidney disease increases this, creatinine is excreted solely by the kidneys
blood urea nitrogen (BUN)- kidneys filter this so if it is high it may indicate kidney disease
glomerular filtration rate (GFR)
color of urine
odor of urine
specific gravity
Peritoneal dialysis
allows exchange of wastes, fluid, and electrolytes to occur in the peritoneal cavity
Complications of peritoneal dialysis
peritonitis (connection site contamination)
pain
exit site and tunnel infections
fibrin clot formation
dialysate leakage
bleeding
bowel perforation
Hemodialysis
removes excess fluids and waste products and restores fluid and electrolyte and acid-base balance
involves passing the patient’s blood through an artificial semipermeable membrane to perform the kidney’s filtering and excretion function
Complications of hemodialysis
hypotension
dialysis disequilibrium syndrome
cardiac events
reaction to dialyzers
access complications (thrombosis, stenosis, infection)
Appendicitis
an acute inflammation of the vermiform appendix that occurs most often among young adults
condition where the appendix becomes inflamed and filled with pus
occurs when the lumen (opening) of the appendix is obstructed which leads to infection as bacteria invades the walls of the appendix
Appendicitis cause
initial obstruction is usually a result of very hard pieces of feces
Appendicitis symptoms
rebound tenderness in the lower right abdominal quadrant
nausea
vomiting
poor appetite
fever
Appendicitis treatment
appendectomy
antibiotics
if untreated can lead to infection (peritonitis) and systemic complications
Ulcerative colitis
widespread chronic inflammation of the rectum and rectosigmoid colon but can extend to the entire colon
periodic remissions and exacerbations
Ulcerative colitis symptoms
bloody and mucusy stool
tenesmus
lower abdominal and colicky pain relieved with defecation
malaise
anorexia
anemia
dehydration
fever
weight loss
Ulcerative Colitis treatments
drug therapy- aminosalicylates, glucocorticoids, antidiarrheal drugs, immunomodulators
may be kept NPO to ensure bowel rest
TPN
nutrition therapy
surgical management for complications of UC
Crohn’s disease
a chronic disease that presents inflammation in the digestive tract that causes thickened bowel walls
can affect any part of the GI tract mouth to anus but usually affects the small intestine and the beginning of the large intestine
recurrent with remissions and exacerbations
Crohn’s Disease symptoms
diarrhea
abdominal pain
low grade fever
weight loss
anemia
Treatments for Crohn’s disease
anti-inflammatory medications-NSAIDs
steroids
immunosuppressive drugs
vitamins
antibiotics
Surgery- bowel resections
self care- dietary fiber
enemas
TPN
Colorectal cancer
cancer of the large intestine
highly curable, especially if diagnosed early
major risk factors- older than 50, genetic predisposition, family history of cancer
Screening for colorectal cancer
starts at 45
colonoscopy every 10 years
people who have a personal or family history will have screening beginning earlier and more frequently
Polyps
small growths covered with mucosa and attached to the surface of the intestine
most are benign
significant because some have the potential to become malignant
Treatment for colorectal cancer
radiation
chemotherapy
colon resection
colectomy
colostomy
abdominoperineal resection
Peritonitis
life threatening acute infalmmation and infection of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity
Peritonitis cause
contamination of the peritoneal cavity by bacteria or chemicals
perforation- appendicitis, diverticulitis, peptic ulcer disease
external penetrating wound
gangrenous gallbladder or bowel segment
bowel obstruction
ascending infection through the genital tract
Peritonitis symptoms
rigid, board-like abdomen
abdominal pain
distended abdomen
nausea, anorexia, vomiting
diminishing bowel sounds
inability to pass flatus or feces
rebound tenderness in the abdomen
high fever
tachycardia
dehydration from high fever
decreased urine output
hiccups
possible compromise in respiratory status
Peritonitis treatment
broad spectrum antibiotics
abdominal surgery may be needed to identify and repair the cause
Enteral feedings
tube feeding
via NET, NG tube, or NDT
PEG
Why are enteral feedings prescribed
If a patient cannot achieve adequate nutrition via oral intake
those who can eat but cannot maintain adequate nutrition by oral intake of food alone (older adults or patients receiving cancer treatment)
those with permanent neuromuscular impairment who cannot swallow (brain attack, severe head trauma, advanced MS)
those who do not have permanent neuromuscular impairment but cannot eat because of their condition
Concerns with enteral feedings
refeeding syndrome
tube misplacement and dislodgment
abdominal distension and nausea/vomiting- caused by overfeeding
fluid and electrolyte imbalances
TPN
this form of nutrition is introduced into the veins
administered with an infusion pump
Care of central line with TPN
Diabetes and kidney failure
AV fistula
an internal anastomosis of an artery to a vein
do not take blood pressure on this arm
takes 2-3 months to form
is used for hemodialysis
AV graft
looped plastic tubing tunneled beneath the skin, connecting, an artery and a vein
do not take blood pressure on this arm
takes 1-3 weeks to be ready
used for hemodialysis
IJ catheter
Chronic kidney disease
progressive, irreversible disorder, lasting more than 3 months
when kidney function and waste elimination are too poor to sustain life, CKD becomes end-stage kidney disease (ESKD)
different stages based on GFR
affects all body systems
CKD fluid restriction
patient is at risk for fluid overload
ability to produce diluted urine is reduced
urine output decreases
extracellular volume can occur because the body loses the ability to secrete sodium
CKD sodium restriction
in the later stages, kidney excretion of sodium is reduced as urine production decreases
it only takes a small increase in dietary sodium to get hypernatremia because they do not have the ability to excrete it from their body
sodium can seem falsely low because water is also being retained (dilution)
Cystoscopy
to identify abnormalities of the bladder wall and urethral and ureteral occlusions
to treat small obstructions of lesions via fulguration, lithotripsy, or removal with a stone basket
an endoscopy scope is inserted through the urethra into the bladder, urethra, and lower portions of the ureters
Concerns post-procedure for cystoscopy
monitor for airway patency and breathing, changes in vital signs, changes in urine output, excessive bleeding, and infection
observe for the complications of bladder puncture (severe pain, nausea, and vomiting)
Acute Kidney injury
when kidney function decline is sudden and results in failure to maintain waste elimination, fluid and electrolyte balance, and acid-base balance
occurs over a few hours or days
can be a temporary condition that resolves or can progress to CKD
affects many body systems, but not all
AKI causes
reduced perfusion to the kidneys (blood or fluid loss, heart attack, sepsis, severe dehydration)
damage to kidney tissue (glomerulonephritis, lupus, blood clot in nearby veins and arteries)
obstruction of urine outflow (bladder cancer, cervical cancer, prostate cancer, kidney stones)
Indicators of Acute Kidney Injury
increase of serum creatinine within 48 hours
urine volume of less than 0.5/ml/hr for 6 hours
decreased GFR (is not a good indicator because it can me impacted by many factors)
Indicators of Chronic Renal Failure
symptoms from every body system
extreme changes in…
creatinine
BUN
sodium
potassium
calcium
phosphorous
bicarbonate
hemoglobin
hematocrit
GFR
Cirrhosis
widespread fibrotic (scarred) bands of connective tissue that change the liver’s anatomy and physiology
in early disease the liver is enlarged and firm
in later disease the liver shrinks and becomes harder
Complications of Cirrhosis
Portal hypertension- persistent increase in pressure within the portal vein that happens due to obstruction or increased resistance of blood flow
Ascites- collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension
Esophageal varices- when fragile, thin walled esophageal veins become distended and torturous from increased pressure
Biliary obstruction
Hepatic encephalopathy- complex cognitive syndrome that results from liver failure and cirrhosis
Causes of Cirrhosis
chronic alcoholism
chronic viral hepatitis
bile duct disease
hepatitis C
hepatitis B
hepatitis D
nonalcoholic fatty liver disease
Signs and symptoms of Cirrhosis
Early
fatigue
significant change in weight
GI symptoms (anorexia, vomiting)
pain in the abdominal area and liver tenderness
Late
GI bleeding
jaundice
ascites
spontaneous bruising
Hepatitis A cause
RNA virus that can be killed by bleach
spread via fecal-oral route by fecal contamination
Hepatitis B cause
Spread through…
unprotected sex
sharing needles
blood transfusions
direct contact with infected blood
birth
Hepatitis C cause
RNA virus
Spread through
transmission is blood to blood
illicit IV drug needle sharing
blood, blood products, or organ transplant before 1992
hemodialysis
Hepatitis D cause
defective RNA virus
occurs only with hepatitis B
transmitted primarily by parenteral routes, mostly IV drug users or unprotected sex
Hepatitis E cause
waterborne infection
caused by fecal contamination of food and water
not common in the US
Fatty liver disease
associated with aging, obesity, diabetes type II, and metabolic syndrome
can progress to liver cancer, cirrhosis, or failure
Cholecystitis
inflammation of the gallbladder
can be acute or chronic
Cholecystitis symptoms
episodic or vague upper abdominal pain or discomfort that can radiate to the right shoulder
pain triggered by a high-fat or high-volume meal
anorexia
nausea and/or vomiting
dyspepsia
eructation
flatulence
feeling of abdominal fullness
rebound tenderness
fever
jaundice, clay colored stools, dark urine
steatorrhea
Causes of Cholecystitis
calculous- chemical irritation and inflammation from gallstones that obstruct the cystic duct, gallbladder neck, or common bile duct
acalculous- associated with biliary stasis caused by any condition that affects the regular filling or emptying of the gallbladder
chronic- repeated episodes of cystic duct obstruction cause chronic inflammation
Treatment of Cholecystitis
treating the pain
extracorporeal shock wave lithotripsy- breaks up large stones
percutaneous transhepatic biliary catheter- opens blocked duct so bile can flow
cholecystectomy- surgical removal of the gallbladder
Causes of Pancreatitis
premature activation of excessive pancreatic enzymes that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas
trauma
pancreatic obstruction (tumor, cysts, absecesses)
metabolic problems (hyperlipidemia, hyperparathyroidism, hypercalcemia)
alcoholism
toxicities of drugs
cigarette smoking and tobacco use
CF
gallstones
Treatment of Pancreatitis
hydration with IV fluids
pain control
drug therapy
withhold food and fluids (NPO)
surgical management is not usually indicated
Complications of Pancreatitis
pancreatic infections
hemorrhage
acute kidney failure
paralytic ileus
hypovolemic shock
pleural effusion
acute respiratory distress syndrome
atelectasis
pneumonia
multiorgan system failure
DIC
Type II diabetes
Intestinal Obstructions
mechanical obstruction
nonmechanical obstruction
Different Types of hernias
indirect inguinal hernia
direct inguinal hernia
femoral hernia
umbilical hernia
incisional or ventral hernia
Treatment for different types of hernias
Different types of IBS
IBS D- diarrhea
IBS C- constipation
IBS A- alternating diarrhea and constipation
IBS M- mix of diarrhea and constipation
Treatment for different types of IBS
IBS D- antidiarrheal agents
IBS C- bulk forming laxatives
IBS A-
IBS M