Acute Exam 4

Manifestations of renal insufficiency

Decreased urine output, although occasionally urine output remains normal, fluid retention, causing swelling in your legs, ankles or feet, shortness of breath, fatigue, confusion, nausea, weakness, irregular heartbeat, chest pain or pressure, seizures or coma in severe cases

Hormonal and regulatory functions of the kidneys

**Hormonal =** renin: helps control blood pressure and raises it when there is a decrease; prostaglandins: the prostaglandins released by the kidneys are specifically to help regulate glomerular filtration, kidney vascular resistance, and renin production; erythropoietin: produced and released in response to decreased oxygen tension in the kidneys blood supply and triggers RBC production in the bone marrow; vitamin D: some kidney activation occurs in the kidneys and it is important because it needs to be activated so that calcium can be absorbed 

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**Regulatory =** __glomerular filtration:__ the first process in urine formation. It is the process in which kidneys start to eliminate toxins and excessive fluid and waste products from the blood; __tubular reabsoprtion:__ second process in urine formation and is when the kidneys reabsorb useful substances such as glucose, amino acids, and electrolytes from the filtrate into the blood and this helps keep urine output at a normal level; t__ubular secretion:__ third process that allows that allows substances to move from the blood into the urine

CT Scans, concern with using dyes

CT contrast materials do rarely cause kidney damage and a skin disorder called nephrogenic systemic fibrosis (NSF) can be caused by the MRI contrast agents.  Patients with poor kidney function are the people at risk for these side effects.

Bladder scans

Noninvasive method of estimating bladder volume. Bladder scans are used to screen for post-void residual volumes and determine the need for intermittent catheterization based on the amount of urine in the bladder rather than the time between catheterizations

Laboratory tests and kidney function (no need-to-know correct values)

**Serum creatinine -** produced when muscles break down proteins; good indication of kidney function only reason it would be high is kidney disease, elevation is when 50% of kidney function is lost

**BUN -** measure of kidneys ability to excrete the U.N; not as good as s.c because it could be high because of other issues (burns, diets, low cardiac output, etc)

**BUN to serum creatinine ratio -** helps to see if it is non-kidney related, an increased ratio may indicate fluid volume deficit, obstructive uropathy, catabolic state, or a high protein diet; low would be fluid volume excess

**Blood osmolarity -** thickness of the blood; good indication of hydration status, if it is high the pt is dehydrated

**Cystatin-C -** if its high then the kidneys are not functioning properly

Peritoneal dialysis, how is it performed, what are some of the complications

Involves siliconized rubber catheter placed into the abdominal cavity for infusion of dialysate

Types: Continuous ambulatory (CAPD), Continuous-cycle (CCPD), Automated (APD), Intermittent (IPD)\`

Complication: Peritonitis - biggest sign is the outflow of the dialysate is cloudy; Pain; Exit site/tunnel infections; Poor dialysate flow - constipated and nowhere for dialysate to go or the positioning; Dialysate leakage; Other complications - bowel perforation, would see brown effluent (outflow)

Hemodialysis, how is it performed, what are some of the complications

During hemodialysis, your blood travels through tubes from your body into a dialysis machine. While your blood is in the machine, it goes through a filter called a dialyzer, which cleans your blood by removing some of the waste and extra fluid. 

Complications: Dialysis disequilibrium syndrome;Cardiac events - generally underlying cardiac issues; Infectious disease; Hepatitis B and C; Human immunodeficiency virus (HIV); Can have a reaction especially the first time similar to an anaphylactic reaction; Hypoglycemia can be a rare reaction; Hemolysis 

Appendicitis

Acute inflammation of the appendix, lrq pain, elevated temp and white count, and only being comfortable in fetal position, pain that increases w/ coughing

Treatment often is a laparoscopic appendectomy 

Ulcerative colitis, treatments, concerns

Creates a widespread inflammation of mainly the rectum and rectosigmoid colon but can extend to the entire colon is the disease is extensive. Periods of exacerbation and remission, pts stools often contain blood.

Many measures are used to relieve symptoms and reduce intestinal motility, decrease inflammation, and promote intestinal healing. Treatment may be nonsurgical - nutrition and drug therapy and in some cases surgery is required to help manage their disease when medical therapies alone are not effective 

Crohn’s, treatments, concerns

Chronic inflammatory disease of the small intestine (most often), the colon, or both. Can affect the GI tract from mouth to anus. CD is a slowly progressive and unpredictable disease and like UC has periods of exacerbation and remission

Treatment - collaborative care for patients with chrons disease is similar to that in the ulcerative colitis section

Colorectal cancer, screening for, polyps, treatment

Often curable but also 3rd leading cancer death in the us found lower in the intestinal tract, normally develops from polyps; can metastasize to other parts of the body mainly liver

RISKS = older than 50, genetic risk (the genetic issue where part of the colon or intestine is lined with polyps), family or personal history of cancer, chron’s or irritable bowel disease, modifiable risk factors 

Radiation would be palliative if it is not going to get better; will also do chemotherapy (will cause leukopenia, and can cause peripheral neuropathy in legs and feet) after the surgical removal, will biopsy lymph nodes around to make sure it hasnt spread, most times will go in and do a colon resection 

Peritonitis

life threatening inflammation of the peritoneal cavity most often caused by bacteria or could be chemicals - any issues with the gut could leave to this (PUD, diverticulitis, wound, bowel obstruction), bacteria can enter blood stream and become septic

Enteral feedings, why are they prescribed, concerns

>  Provides nutrients into the GI tract

>  Preferred method of meeting nutritional needs if

    patient is unable to swallow yet has a functioning GI

    tract.

>  Serious complication – aspiration

TPN, what is it, care of central line

>  Specialized nutritional support provided 

    intravenously.

>  Patients who are unable to digest or absorb EN 

    benefit from PN.

Diabetes and kidney failure

Identifying patients with diabetes is important to prevent CKD; instruct patients with diabetes to keep their blood glucose level within the prescribed range 

AV fistula, AV graft, IJ catheter

Arteriovenous (AV) fistula or graft for long-term permanent access, Hemodialysis catheter, dual or triple lumen, or AV shunt for temporary access; IJ = intrajugular

CKD – fluid restriction, sodium restriction

Will have to adjust their diet - sodium, potassium, protein, and cholesterol restrictions, limit alcohol intake, People in the later stages of chronic kidney disease (CKD) should limit fluid intake because as kidney function is lost the kidneys can no longer remove excess fluid, which can lead to serious complications

Cystoscopy, concerns post-procedure

Chronic Kidney Disease, Acute Kidney Injury

**AKI =** a rapid reduction in kidney function resulting in a failure to maintain waste elimination, fluid and electrolyte balance, and acid base balanc. Occurs over a few hours or days - an increase in serum creatinine by 0.3 or more within 48 hrs or an increase to 1.5 times above baseline - 3 types: prerenal, intarenal, and postrenal 

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**CKD =** progressive, irreversible disorder and kidney function does not recover. Abnormalities in kidney function or structure that alter health and are present for 3 months; five stages based on the glomerular filtration rate - the slower the rate the more severe: 1 = > 90 at risk, 2 = 60-89 mild, 3 = 30-59 moderate, 4 = 15-29 severe, and 5 = < 15 end stage

Indicators of Acute Kidney Injury

Decreased urine output, buildup of nitrogenous wastes, if AKI is progressing in severity the patient may have symptoms of fluid overload including pulmonary crackles, dependent and generalized edema (anasarca), decreased oxygenatoin, confusion, increased respiratory rate, and dyspnea

Indicators of Chronic Renal Failure

CKD causes changes in all body systems, most symptoms are related to changes in fluid and electrolyte balance, acid base balance, and buildup of nitrogenous wastes

Cirrhosis, causes, signs/symptoms, complications of

Cirrhosis = extensive, irreversible scarring of the liver usually caused by a chronic reaction to hepatic inflammation and necrosis. There are two types compensated (when there is scarring and cellular regulation is impaired but the organ can still perform its essential function and doesnt cause any major symptoms) decompensated (when liver function is impaired with obvious signs and symptoms)

Causes = chronic alcoholism, chronic viral hepatitis, nonalcoholic steatohepatitis (fatty liver disease), bile duct disease, genetic disease

Complications = portal hypertension, ascities and gastroesophageal varices (these can burst which would be an emergent situation bc the pt could bleed out), hepatic encephalopathy - build up of ammonia in the blood cause the cognitive problem and gives the pt lactulose to have diarrhea; hepatorenal issues, bacteria in the fluid, production of bile is decreased and it causes fat soluble vitamins to not be absorbed such as vitamin k, jaundice - which is back of bilirubin which is the breakdown of red blood cells

Hep A-E, what is the cause

**Hepatitis:** wide spread inflammation of liver cells 

* Can be viral (a,b,c,d,e - vary in mode of transition, incubation period, severity), herbs, drugs etc that cause it
* Can be acute or chronic 

Hep a: more mild, fecal oral, not as severe - normally contaminated food or water 

B: sexual transmission, needle sticks etc (many people vaccinated and need to in health care), person to person can share open wound cut - high risk people should be screened; blood test confirms disease (most adults recover from this and develop immunity, others are carries which increases risk or cirrhosis or liver cancer)

C: blood to blood: needles, tattoos in an unsanitary location,  not transmitted through casual contact - asymptomatic and should screen high risk 

D: only occurs with hep b

E: waterborne infection associated with epidemics  - normally contaminated food or water 

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Hep c is most common bc no vaccine, a and b has decreased because it has a vaccine

Fatty liver disease

Fatty liver disease is a condition in which fat builds up in your liver. There are two main types: Nonalcoholic fatty liver disease (NAFLD), Alcoholic fatty liver disease, also called alcoholic steatohepatitis

Simple fatty liver, in which you have fat in your liver but little or no inflammation or liver cell damage. Simple fatty liver typically does not get bad enough to cause liver damage or complications.

Nonalcoholic steatohepatitis (NASH), in which you have inflammation and liver cell damage, as well as fat in your liver. Inflammation and liver cell damage can cause fibrosis, or scarring, of the liver. NASH may lead to cirrhosis or liver cancer.

Cholecystitis, causes, treatment

Inflammation of the gall bladder

Acute Cholecystitis - calculus (stone formation; most common - often blocks the common bile duct) or acalculus (without a stone caused by biliary stasis - not being pushed along as it should; sludge)

Chronic Cholecystitis - when repeated episodes of cystic duct obstruction cause chronic inflammation. can be familial or as a result of high fat diets 

Make sure the patient is getting adequate nutriton (high in fiber, low in fats, avoid gas producing foods)- this is bc pts may decline food because of abdominal discomfort or nausea. 

Addressing pain is a top priority, a non-surgical option would be like how they can get rid of kidney stones - extracorporeal shock wave lithotripsy, or a percutaneous transhepatic biliary catheter 

Pancreatitis, causes, treatments, complications

**ACUTE:**

Serious and at times a life-threatening inflammation of the pancreas - caused by excessive production of pancreatic enzymes 

Pancreas – functions as both an exocrine (aids with digestion) gland and an endocrine gland (insulin and glucagon)

Complications of acute pancreatitis - jaundice, intermittent hyperglycemia, pleural effusion (specifically left side), pneumonia, multi-organ failure caused by the pancreas becoming necrotic 

Treatment - supportive care by relieving symptoms, continually assess the ABCs, Mild = requires hydration with IV fluids, pain control, and drug therapy; if the patient has a life-threatening complication they will be admitted to a cartical care unit for invasive hemodynamic monitoring

**CHRONIC:**

Progressive, destructive disease of the pancreas that has remissions and exacerbations.

Chronic Calcifying Pancreatitis (CCP) - most common (pancreas itself is getting hardened), Chronic Obstructive Pancreatitis, Autoimmune Pancreatitis, Idiopathic and Hereditary Chronic Pancreatitis

Treatment - drug and nutrition therapy

Intestinal obstructions

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* Mechanical: tumor, adhesions 
* Nonmechanical: Chron’s; most of these respond well to ng tube 
* Strangulated: compromises blood flow and can cause necrosis to the area - emergent and need surgery to correct it 
* Intussusception: telescoping into itself
* Volvulus: the twisting of the bowel
* Peritonitis: inflammation of the peritoneum - can be caused by this

Different types of hernia’s, treatment for

* Indirect inguinal hernia
* Direct inguinal hernia
* Femoral hernia
* Umbilical hernia
* Incisional ventral hernia
* Reducible, Irreducible
* Strangulated

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Any hernia that is not reducible requires immediate surgical intervention; most hernias are inguinal and surgical treatment occurs most frequently, if the patient is nonsurgical can be treated with a truss - pad made with firm material and held in place with a belt

IBS, different types, treatment for

Most common digestive disorder >  One in five people in the U.S.

Classifications: >  IBS-D (diarrhea), >  IBS-C (constipation), >  IBS-A (alternating diarrhea/constipation), >  IBS-M (mix of diarrhea/constipation)

Etiology:  Unclear

Symptoms begin in young adulthood and continue through life; stress and anxiety, environmental factors etc 

Women are 2x more likely to experience this than men

Treatment is often self management strategies - CAM such as probiotics, different treatment depending on the type such as IBS-D would be treated with antidiarrheals or IBS-C treated with a laxative