Medical-Surgical Nursing Review

Final Exam

Kidney Functions

Removal of metabolism byproducts and toxins, regulate ions, protect organs by maintaining acid-base balance, maintain F&E balance, produce erythropoietin & renin, convert vitamin D.

Kidney Labs

Blood urea nitrogen (BUN): 10-20; Serum Creatinine (Cr): <2.0; Glomerular Filtration Rate (GFR): 90-120

Nephrons

Functional units of the kidneys that filter waste from blood and produce urine.

Glomerulus

Part of the nephron that allows waste and fluid to pass but keeps large molecules like protein in the blood.

Renal Circulation

Blood enters kidney via renal artery; blood leaves kidney via renal vein.

Ureters

Muscular layers that use peristalsis to transport urine from kidneys to bladder.

Bladder

Located in pubic symphysis; held in place by pelvic diaphragm muscles and ligaments. Contraction of urethral sphincters stops urine flow.

Male Urethra Length

15-20 cm; Cowper glands secrete mucus into membranous urethra.

Female Urethra Length

4 cm; Extends to external orifice between labia minora.

Urine Formation

Begins with glomerular filtration driven by hydrostatic pressure; filters blood, plasma, and solutes.

Glomerular Filtration Rate (GFR)

Amount of blood & plasma filtered per minute; normal is 90-120 mL/min x 1.73; regulated by afferent arteriole constriction/dilation and sympathetic NS/RAAS.

Hemodynamic Stability and Kidneys

Kidneys work with the cardiovascular system; kidney function is affected by decreased blood flow.

Urinary Tract Infection

Infection in the bladder, kidneys, ureters, or urethra; most common cause is E. coli.

Uncomplicated UTI

UTI anywhere in tract with bacteria and no comorbidities; low risk of complication.

Recurrent UTI

Occurrence of 2+ incidences of symptoms within 6 months or 3 within 12 months.

CAUTIs

Health Care-Associated UTIs due to indwelling catheters; biofilms form on catheter surface allowing bacteria to enter.

Manifestations of UTI in Aging Adults

New onset confusion, new onset urinary incontinence, lack of appetite, lethargy, and low grade fever/no fever.

Clinical Presentation for UTI

Increased urination/frequency/hesitation, dysuria, suprapubic pain, leaking, nocturia, urine retention/incomplete emptying.

Lab Tests for UTIs

Clean catch urine, urine dipstick testing pH, hematuria, leukocyte esterase, nitrates, urine culture for causative agent, CBC.

Safety Considerations for UTIs

Elevated blood sugars increase risk of UTI; diabetes can decrease sensation; urgency/frequency increases risk of falls.

Client Education for UTIs

Take antibiotics as prescribed, control blood sugars, drink 2-3 L of fluids/day, maintain adequate hydration, females wipe front to back/urinate after sex/shower instead of bathe/empty bladder often.

Cranberry for UTIs

Used for treatment & prevention due to effect on ability of bacteria to adhere to uroepithelium.

Trimethoprim/sulfamethoxazole (bactrim) Considerations

Contraindicated in sulfa allergy/pregnancy; Adverse Effects: stevens-johnson syndrome, hypoglycemia, diarrhea, aplastic anemia; routes: orally, IV, *do not give IM

Nitrofurantoin Considerations

Anti-infective; contraindicated in sensitivity to parabens; Adverse Effects: pulmonary fibrosis, hepatotoxicity, diarrhea; urine may become rust-yellow or brown.

Fluoroquinolones (ciprofloxacin) Considerations

Contraindicated in myasthenia gravis, pregnancy, or taking tizanidine/theophylline; do not use concurrently with NSAIDs and phenytoin; Adverse Effects: increased intracranial pressure, seizures, suicidal thoughts, hepatotoxicity; do not take with antacids or meds with zinc/iron.

Phenazopyridine (Pyridium) Considerations

Treats discomfort, burning, and dysuria; contraindicated in renal/hepatic impairment; Adverse Effects: hepatotoxicity, rash, renal failure; bright orange/brown urine; take orally with full glass of water; stains clothes and contact lenses.

Incontinence

Involuntary loss of urine.

Urge Incontinence

Detrusor muscle overactivity that causes bladder contraction; loss of neurologic control or irritation of the bladder.

Overflow Incontinence

Urine leakage of overdistended bladder due to obstruction or impaired contractility of detrusor muscle.

Risk Factors for Incontinence

Alcohol, chili peppers, spicy/sugary foods, caffeine, hypertension, diuretics, alpha blockers, antidepressants, opioids, calcium channel blockers, ACE inhibitors, pregnancy.

Considerations of Aging Adult with Incontinence

Increased risk for falls, decreased activity levels, decreased strength of detrusor muscles, decreased bladder capacity, increased residual urine volume, diminished pelvic floor muscle tone, post-menopause.

Urinary Antispasmodics (Ditropan XL, oxybutynin) Considerations

Do not give to those with angle-closure glaucoma, bowel obstruction, urinary retention; Adverse Effects: drowsiness, blurred vision, confusion, chest pain, dry mouth, decreased sweating, urinary retention, allergic reaction; avoid exercise in intense conditions, avoid alcohol/CNS depressants.

Bladder Relaxants (Myrbetriq) Considerations

Contraindicated in those with renal/hepatic impairment, hypertension; Adverse Effects: hypertension, headache, tachycardia.

Bladder Training

Keep fluid intake same throughout training period; increase time duration by 30 min/session; deep breathing & count to 10 while contracting the pelvic floor muscles; hold pressure on perineal area; start positive self-talk.

Pelvic Floor Muscle Training

Squeeze pelvic floor muscles for 10 sec, hold tight for 10 sec, relax for 10 sec; kegel exercises.

Urinary Retention

Inability to void and empty bladder.

Most Common Male Causes of Urinary Retention

Obstruction due to BPH.

Treatments for Urinary Retention

Endoscopic treatments, open surgical procedures, 5-alpha reductase inhibitors, alpha-blockers.

5-alpha reductase inhibitors (finasteride/Proscar) Considerations

Inhibit prostate growth; contraindicated in females; Adverse Effects: cancer of prostate and breast, increased breast tissue, sexual dysfunction; can cause risk to male fetus, avoid husband’s semen if wife is pregnant.

Benign Prostatic Hyperplasia (BPH)

Non-cancerous growth of prostatic tissue that can compress the urethra.

Comorbidities Associated with BPH

Metabolic syndrome, obesity.

Clinical Presentation of BPH

Urinary frequency/urgency, difficulty initiating urine stream, dysuria, nocturia, urinary retention.

Treatment for BPH

Lifestyle modifications, medications, surgical management.

Pyelonephritis

Acute: Severe kidney infection that causes kidneys to swell; Patho: bacteria enters through urethra, spreads to bladder, then spreads to kidneys by traveling up ureters.

Complications of Pyelonephritis

Formation of renal abscesses, thrombosis in renal vein, acute renal failure.

Polycystic Kidney Disease (PKD)

Inherited disorder that causes fluid-filled cysts to develop in kidneys.

Avoid During PKD

Avoid ibuprofen, naproxen, or NSAIDs.

Acute Glomerulonephritis

Usually caused by streptococcus/stapholococcus; immune-mediated damage to glomerulus leading to proteinuria, azotemia, and hematuria.

Glomerulonephritis

Sharp decline in glomerular function as antibodies form against glomerular membrane causing cell proliferation into the Bowman’s capsule.

Kidney stones

Renal Calculi

Extracorporeal Shockwave Lithotripsy (ESWL)

Destroys kidney stones in kidney and upper ureter.

Acute Kidney Failure

Sudden onset and a (usually reversible) decrease in kidney function.

Fluid Challenge

Determines if acute renal failure is pre-renal.

Loop Diuretics (furosemide) Considerations for AKF

Contraindicated in kidneys not producing urine / those in hepatic coma; Adverse Effects: stevens-johnson syndrome, photosensitivity, F&E imbalances, increased liver enzymes, elevated blood sugar in diabetics, muscle cramps.

Nephrotoxic Medications

Vancomycin, tetracycline, pantoprazole, omeprazole, methotrexate, lithium, cortisone, cimetidine, aspirin, allopurinol, acetaminophen

Chronic Kidney Disease (CKD)

Gradual loss of kidney function overtime; complete recovery is not possible due to the permanent damage sustained by the kidneys.

Risk Factors for CKD

Diabetes mellitus, systemic hypertension, proteinuria, dyslipidemia, hyperuricemia, and insulin resistance & race/ethnicity, gender/age.

Dialysis Diet

Sodium Control (less than 2300 mg/day), protein small portions, limit saturated and trans fats, poultry without skin, fruits, low or fat free products.

Complications from Hemodialysis

Htn, diabetes mellitus, Hyperlipidemia, cerebrovascular disease, malignancies, liver disease

Peritoneal Dialysis

Placement of sterile dialysate fluid in the abdomen and blood is filtered within the abdomen.

Addison’s Disease

Glands are damaged and unable to produce adequate amounts of cortisol and aldosterone.

Cushing’s Syndrome

Excessive amounts of cortisol are excreted.

Hypothalamic-pituitary axis

Hypothalamus receives feedback from multiple areas and sends a message to the pituitary gland to release or hold hormones.

TSH

Anterior pituitary to stimulate release of thyroid hormones.

Anterior Pituitary Gland

Releases TSH; stimulates the thyroid gland to release triiodothyronine (T3) and thyroxine (T4) hormones which regulates metabolism.

Adrenal Glands

Located on kidneys and secrete cortisol and aldosterone.

Exocrine Glands of Pancreas

Secretes enzymes for digestion ;amylase and lipase

Endocrine Glands of Pancreas

Secretes insulin in beta glands or glucagon to regulate blood glucose levels.

Glucagon

Released in response to low blood sugar levels.

Insulin

Unlocks the cell to allow for the absorption of glucose when blood sugar levels are high.

Gluconeogenesis

Production of glucose from amino acids and the breakdown of adipose (proteins, lipids, pyruvate, or lactate).

Glycogenolysis

Production of glucose from the breakdown of glycogen in the liver.

Excess Blood Glucose Leads To

Polyuria: excessive urination leading to dehydration; Polyphagia: excess hunger leading to overeating; polydipsia.

HbA1C Goal

<6%

Sulfonylureas Considerations

Decreases blood glucose by increasing insulin secretion from beta cells in pancreas; Adverse Effects: hypoglycemia, weight gain, nausea, diarrhea, dizziness, and headache; take 30 min before or with first meal of day.

Biguanides: metformin Considerations

Decreases amount of glucose produced in liver and decreases amount of glucose absorbed from food; Adverse Effects: indigestion, bloating, abdominal pain, constipation, headache, and metallic taste; do not take if NPO

Dipeptidyl Peptidase-4 inhibitor Considerations

Increases insulin production and lowers glucagon secretion; Adverse Effects: upper respiratory infection, runny nose, indigestion, edema, changes in urination, and diarrhea; take with or without food

Sodium-Glucose Transport Protein 2 Inhibitor Considerations

Decreases renal glucose reabsorption and increases elimination of glucose by urination; Adverse Effects: UTIs, increased urination, increased thirst, nausea, constipation; monitor renal function; take before first meal of day; hold before surgical procedures.

Hypoglycemia Signs

Headache, sweating, tachycardia, irritability, restlessness, excessive hunger, dizziness

15 grams of Fast Acting Carbohydrates

3-4 glucose tablets, 6-8 hard candies or gummies, 8 oz low fat or skim milk, 1 tbsp corn syrup, sugar, or honey, ½ (4 oz) 100% fruit juice or regular soda, 2 tbsp of raisins, 4-5 crackers

Type I Diabetes Mellitus

Autoimmune disease that involves the destruction of beta cells in the pancreas where insulin is produced.

Types of T1DM presentation on dx

1. Presence of greater than 2 or more pancreatic autoantibodies 2. HbA1C between 5.7-6.4%, impaired glucose tolerance, and the presence of two pancreatic autoantibodies

During Sickness Considerations for T1DM

Consume 4-6 oz of carbs every 30 minutes; Eat at least 50 g of carbs every 4 hours; Monitor weight daily, weight loss can be indication of hyperglycemia.

S/S of Dx for T1DM

Nonfasting Glucose- 200 mg/dL or higher; Fasting Glucose- 126 mg/dL or higher; HbA1C- 7% or higher ; C-Peptide Levels are decreased

Signs of DKA

Increased thirst (polydipsia); Fatigue ; Nausea/Vomiting

When to go the ER with T1DM

Weight loss of more than 5 lbs, inability to keep down fluids for over 4 hours or food for over 24 hours

Type 2 Diabetes Mellitus

Some insulin production but not sufficient to maintain blood glucose levels; insulin resistance in insulin receptors in body tissues.

S/S of T2DM Labs

C-Peptide levels are increased or normal; urine tests can reveal atypical levels of glucose, protein, or ketones Two abnormal results must come back

Metabolic Syndrome

Elevated blood pressure, glucose, and cholesterol; insulin resistance.

Hypothyroidism Causes

1–iodine deficiency; Hashimoto’s Disease

Considerations of Aging Adult with Hyperthyroidism

Risk of hypothyroidism increases with age; Levothyroxine: contraindicated for adults

Levothyroxine

Must be taken 1 hour before meals or 3 hours after meals Side Effects: tachycardia, fever, anxiety, palpitations, weight loss, appetite changes, and sweating.

Hyperthyroidism Causes

Graves’ Disease: autoimmune disorder that causes a client’s thyroid to produce too much thyroxine; Toxic Multinodular Goiter; Postpartum Thyroiditis

Antithyroid meds include

methimazole or propylthiouracil used to decreae thyroid prod

Nervous System

CNS: consists of brain and spinal cord; PNS: consists of spinal and cranial nerves and ANS & SNS

Autonomic Nervous System (ANS)

Sympathetic, parasympathetic, and enteric nervous system

PNS

Spinal and cranial nerves with ANS & SNS(Symp & somatic )

Primary Headaches

Migraines, cluster headaches, and tension-type headaches (TTH)

Secondary Headaches

Secondary Headaches: caused by underlying health condition including trauma, infections, intracranial disorders

Migraines

Recurrent headaches lasting 4-72 hours; throbbing or pulsing pain that triggers sensitivity of light/sound/odor