Acute Exam 4

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

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Prostaglandins- help regulate glomerular filtration, kidney vascular resistance, and renin production

* increase sodium and water excretion

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Erythropoietin- produced and released in response to decreased oxygen in the kidney’s blood supply

* triggers RBC production in the bone marrow

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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

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* 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

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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