med surg 3

Kidney/urinary system changes associated with aging

cortical tissue loss and smaller nephrons

reduced blood flow to kidneys

decreased tubule length

decreased GFR

nocturia

risk for dehydration

tendency to retain urine

weakened urinary sphincters and shortened urethra in women

Factors contributing to UTI

obstruction

stones

vesicoureteral reflux

DM

urine concentration/pH

gender

age

sexual activity

recent use of abx

virulence factors

Key features of Chronic Pyelonephritis

hypertension

inability to conserve sodium

decreased ability to concentrate urine

development of hyperkalemia and acidosis

Kidney issues, geriatric considerations

normal decline with aging (renal blood flow less than 10%/10 yrs)

concentrate urine less

decreased ability to excrete drugs including contrast/dyes

comorbidities (diabetes, htn)

prescribed meds

Chronic kidney disease (CKD) changes

metabolic changes

cardiac changes

hematologic and immunity changes

GI changes

cognitive and functional changes

CKD changes; metabolic

fluid and electrolyte balance is disrupted

acid-base balance is disrupted

CKD changes; cardiac

htn

hyperlipidemia

heart failure

pericarditis

CKD clinical manifestations

Hemodialysis nursing care

drugs

postdialysis assessment

• htn

• headache

• nausea, vomiting

• malaise, dizziness

• muscle cramps/bleeding

Complications of Peritoneal Dialysis

peritonitis

pain

exit site/tunnel infections

poor dialysate flow

other complications

Risk for dehydration in renal issues due to…

lowering of concentration of urine

GFR normal values

90-120

60 for those 40+ yrs old

Serum creatinine value

males - 0.6-1.2 mg/dL

females - 0.5-1.1 mg/dL

increased levels means kidney impairment

decreased levels means decreased muscle mass

BUN value

10-20 mg/dL (older adults higher)

increased level means liver/kidney disease, dehydration or decreased kidney perfusion, high protein diet, infection, stress, steroid use, and GI bleeding

decreased level means malnutrition, fluid volume excess, or severe hepatic damage

BUN/creatinine ratio value

6-25

increased ratio means fluid volume deficit, obstructive uropathy, catabolic state, or high protein diet

decreased ration means fluid volume excess

We avoid ____ with CT contrast

metformin and shellfish

Assessing a pt undergoing kidney test/procedures with contrast

allergies?

asthma?

hay fever?

metformin?

assess renal status and hydration status

Factors contributing to urinary incontinence

drugs

disease

depression

inadequate resources

Drugs, urinary incontinence

CNS depressants/opioids - decrease pts LOC and urge to void → constipation

diuretics - frequent/large amounts of urine

multiple drugs - change in mental status or mobility, can irritate bladder

anticholinergic - affect both cognition and ability to void

disease, urinary incontinence

stroke, parkinsons, dementia, and other neuro disorders decrease mobility, sensation, or cognition

arthritis - decreases mobility and causes pain

depression, urinary incontinence

decreases the energy necessary to maintain continence

decreased self-esteem and feelings of self-worth decrease the importance to the pt of maintaining continence

inadequate resources, urinary incontinence

pts who need assistive devices may be afraid to ambulate w/o them

products the help manage incontinence are costly

no one may be available to assists them

60% of women ages…

65+ have incontinence

Urodynamic testing

seeing how much a pt can hold in before having to go

Types of incontinence

stress

urge

mixed

overflow

functional

Stress incontinence

involuntary loss of urine during activities that cause that increase abdominal and detrusor pressure; inability to tighten urethra

most common

Stress incontinence management

weight reduction

smoking cessation

pelvic muscle therapy

vaginal cone therapy

bladder training

estrogen therapy

electrical stim

magnetic resonance therapy

pessary devices

surgery

Urge incontinence

overactive bladder; involuntary loss of urine associated with a strong desire to urinate; inability to suppress the signal from the bladder muscle to the brain that it is time to go

Urge incontinence management

bladder therapy

pelvis muscle therapy

weight reduction

avoid bladder irritants (caffeine, alcohol)

smoking cessation

drug therapy

electrical stim

surgery

Mixed incontinence

combination of stress and urge incontinence

same management as urge/stress

Overflow incontinence

involuntary loss of urine associated with overdistention of the bladder when bladder capacity has reached its max; detrusor under activity, bladder outlet obstruction

Overflow incontinence management

bladder training

bladder compression

intermittent self-cath

drug therapy

nonsurgical treatment unless needed

Functional incontinence

leakage of urine caused by factors other than disease of the lower urinary tract

Functional incontinence management

habit training

prompted voiding is used to establish a predictable pattern

devices → intravaginal pessaries, penile clamps, condom cath

intermittent/long-term cath

Ways to prevent a UTI

drink 2-3L of fluid daily

get enough sleep and nutrition daily (better immune health)

change from spermicide use

avoid routinely delaying urination

Manage CAUTIs

maintain good hygiene during insertion and manipulation of cath

insert cath for appropriate use only

ensure properly trained personnel insert and maintain cath

routinely clean periurethral area

leave in only as long as needed

maintain unobstructed urine flow

secure cath to thigh/abd to avoid friction

consider alt to indwelling caths

Hydroureter

swollen ureter due to backup of urine

Hydronephrosis

one or both kidneys swell, urine doesn’t fully empty from body

how frequent for chronic pyelonephritis

two a year

CRP (c-reactive protein)

lab that shows inflammation

Hyperkalemia causes…

heart problems

Collaborative management example

having to deal with with both kidney damage and hypertension

MAP

60-75

Renal diet

lower protein since kidneys cannot manage it as well

What we assess in dialysis pts fistulas

thrill - feel woosh

bruit - hear woosh

if these are missing it means there is a clot → medical emergency

Dialysis disequilibrium syndrome

result of a rapid reduction in electrolytes; characterized by mental status changes and can include seizures or coma

Drain bag from dialysis should be…

clear, if it is cloudy there may be an infection

Lab assessments before surgery

urinalysis

blood type/screen

CBC or hemoglobin/hematocrit

clotting studies (PT, INR, aPTT)
electrolyte levels

serum creatinine level

pregnancy test

chest xray

ecg

Informed consent

surgeon obtains signed consent before sedation and/or surgery (risks and benefits)

nurse witness for speaking to the surgeon and that the pt is alert and oriented

nurse not responsible for providing detailed info about procedure

telephone requires two nurses

special permits - contrast/blood/MRI/implants

pt self-determination - only the pt can sign unless they are incapacitated, next of kin

older adults surgical risk

decreased

• cardiac output, peripheral circulation

• vital capacity, blood oxygenation

• blood flow to kidneys, GFR

increased

• BP

• risk for skin damage, infection

• sensory deficits

• deformities related to osteoporosis/arthritis

Pts at risk for VTE

obese

40+

history of cancer or decreased CO

decreased mobility, immobile, spinal cord injury

history of VTE, PE, varicose veins, edema

oral contraceptives

smoking

hip fracture, total hip/knee surgery

PACU respiratory assessment

patent airway, adequate gas exchange

note artificial airway

rate, pattern, depth of breathing

breath sounds

accessory muscle use

snoring and stridor

respiratory depression or hypoxemia

Preventing wound infection

dressings - first change done by surgeon

drains - provide exit route for air, blood, bile

incision - well approximated

drug therapy, irrigation to treat wound infection

debridement

surgical management

Elective surgery

chose to

Emergent surgery

don’t need consent, two doctors musts say it is an emergency

Malignant hyperthermia

allergy; genetic factor that causes a pt to not be able to metabolize gases (anesthesia) the same and they could die

Common when waking up from anesthesia

puking, crying, swinging

Medicine and cardiac clearance

primary doctor assesses pt and labels if they are at risk for anesthesia

Urinanalysis checks for preoperative care

renal function and infections

CBC/WBC checks for in preoperative care

infection

Hemoglobin/hematocrit checks for in preoperative care

other issues if there is no sign of infection

Electrolyte levels check for in preoperative care

sodium and potassium

JP drain

used to collect drainage from wound when bulb is squeezed drawing out the fluid

Pen rose

used for a site with a small amount of drainage, a tube that allows fluid to seep in and drain out, with gauze catching it

Hemovac

used for larger surgeries due to more drainage room, vacuum pressure by remaining collapsed to pull fluid out

• measure drainage by pouring it into a container

Serous drainage

clear, yellow; normal in early stages of the healing process

Sanguineous drainage

bright red, bloody; common right after a surgery (24-48hrs) but should decrease

Serosanguineous drainage

pinkish; normal transition from sanguineous to serous in would healing

Atelectasis

common during anesthesia and postop; partially lung collapse that could lead to infection and other respiratory complications

How can pain affect a pts condition after surgery?

it could make them not want to move which increases the chance for clots and have shallow breaths which could cause atelectasis or pneumonia

Diabetic ketoacidosis

hyperglycemia causing hypotension, polyuria, polydypsia, hyperventilation, fruity/acetone breath, tachycardia

Somogyi effect (rebound)

hypoglycemia at night leads to hyperglycemia in the morning

• avoid with less insulin at night or a snack

Dawn phenomenon

hyperglycemia in the early morning

• avoid by increasing insulin

Type 1 DM

acute onset; polyphagia, polydypsia, polyuria

Type 2 DM

gradual, insidious onset; polys + fatigue, recurrent infections, prolonged wound healing visual changes

Medical management of DM

nutrition therapy, physical activity, surgery (pancreas transplant), medication management

Basal insulin

long acting and type 1 DM can never be off of it

A1C

test measuring the average amount of sugar in your blood over the past few months used to diagnose prediabetes and to monitor treatment plans

Nursing management assessment of DM

blood glucose monitoring

labs

hypo/hyperglycemia

skin integrity

medication adherence

lifestyle

Hypoglycemia signs/symptoms

confusion, irritability, diaphoresis, tremors, hunger, weakness, visual disturbances

Hyperglycemia signs/symptoms

weakness

malaise

visual changes

polys

weight loss

Managing hypoglycemia with an alert and can eat pt

15 gm of quick acting oral CHO, repeat BG in 15 mins

repeat until BG is within normal range, then offer a protein snack

Managing hypoglycemia with a pt who is poorly responsive/unresponsive with no IV access

call rapid response and administer glucagon

Managing hypoglycemia with a pt who is poorly responsive/unresponsive with IV access

call rapid response and administer IV D50