hesi REnal

Chapter 4 Medical-Surgical Nursing

F. Anxiety Management

1. Information Provision

  • Maintain communication by keeping the client and their family informed about impending tests and procedures.

2. Promote Control

  • Allow the client as much control as possible over their personal care decisions.

3. Encourage Expression

  • Encourage both the client and their family members to verbalize any concerns they might have, facilitating an open dialogue about fears and uncertainties.

G. Pain Management

1. Analgesic Administration

  • Administer analgesics as needed to manage pain to a tolerable level. Ensure that the dosage is within the safety range, particularly concerning respiratory difficulties.

H. Surgical Interventions

1. Thoracotomy

  • Indicated for clients who have a resectable tumor. However, late-stage detection often results in tumors being unresectable.

2. Pneumonectomy

  • Complete removal of an entire lung.

    • Positioning: Client should be positioned either on the operative side or on their back.

    • Chest Tube Usage: Chest tubes are typically not required after a pneumonectomy.

3. Lobectomy and Segmental Resection

  • Positioning: The client is generally positioned on their back.

  • Chest Tubes: Chest tubes are usually placed to facilitate drainage during recovery post-surgery.

    • Monitoring: Check to ensure that the chest tubes are not kinked or obstructed.

    • HESI Hint: In cases where large tumors necessitate removal of entire lobes, chest tubes may not be prescribed to allow the mediastinal space to fill with fluid, preventing the shift of surrounding organs.

4. Chest Tube Management

  • Maintain all tubing coiled loosely below chest level. Ensure that connections are tight and securely taped.

  • Water Seal Maintenance: Ensure the water seal and suction control chamber are maintained at appropriate levels.

  • Fluid Monitoring: Regularly monitor fluid drainage, documenting the time and fluid level.

  • Observation for Air: Watch for bubbling in the water seal chamber and fluctuations in fluid levels (tidaling).

  • Patient Status Monitoring: Consistently monitor the client’s clinical status and check the position of the chest drainage system. Encourage deep breathing exercises periodically.

  • Collection Container: Do not empty the collection container of the chest tube; replace it when it becomes full.

  • Tube management: Avoid stripping or milking chest tubes and do not routinely clamp them. In case of a broken drainage system, the distal end of the chest tube should be placed in sterile water as an emergency measure for water sealing. Maintain a dry, occlusive dressing over the chest tube site.

  • If dislodged, cover with a sterile dressing taped on three sides, allowing air to escape, preventing tension pneumothorax. Notify the healthcare provider.

Figure 4.3: Chest Tubes – Used for drainage of blood/air, expanding the lung post-surgery, or restoring subatmospheric pressure in the thoracic cavity. Most commercial drainage systems adhere to the three-bottle water seal system concept.

5. Key Assessment Points for Chest Tubes (HESI Hint)

  • Fluctuations (tidaling) indicate system integrity when no external suction is present. Movement should coincide with client’s breathing patterns. If fluctuations cease, inspect for kinks or obstructions in the tubing. Continuous bubbling indicates a potential air leak.

I. Chemotherapy Management

1. Immunosuppression Monitoring

  • Be attentive to immunosuppression factors as outlined in “Hematology and Oncology” sections.

Review of the Respiratory System

1. Common Symptoms of Pneumonia

  1. Specific symptoms that can be identified during a physical examination.

2. Nursing Interventions for Coughing

  • Four interventions to assist clients in creating productive coughs are required.

3. Symptoms in Older Clients

  • Recognize symptoms of pneumonia that may be more subtle in older adults.

4. Hypoxia Prevention

  • Details on preventing hypoxia during suctioning procedures.

5. Major Nursing Interventions during Mechanical Ventilation

  • Identification of three critical nursing interventions.

6. Findings in Emphysema Patients

  • Expected physical findings during the assessment of a client with emphysema.

7. Lung Cancer Risk Factors

  • Identify the primary risk factor associated with lung cancer.

Renal System

A. Acute Kidney Injury (AKI)

Description: A potentially reversible condition characterized by rapid loss of kidney function, indicated by an increase in serum creatinine and/or a decrease in urine output.

HESI Hint

  • The kidneys excrete approximately 1 mL of urine per kg of body weight per hour. Typical adult urine output is between 1500 and 2000 mL/day depending on various factors (fluid intake, perspiration, temperature, gastrointestinal losses).

B. Types of AKI

  • There are three main categories of acute kidney injury.

C. Phases of AKI

  1. Oliguric Phase: Defined as urine output of less than 0.5 mL/kg/h for children, and less than 400 mL daily for adults.

  2. Diuretic Phase: Characterized by daily urine output exceeding 400 mL.

  3. Recovery Phase: Glomerular filtration rate (GFR) returns to 70% to 80% of baseline levels.

HESI Hint

  • GFR is an essential marker measuring kidney functionality, estimating how much blood is filtered through the glomeruli per minute.

D. Nursing Assessment Factors

  1. History including nephrotoxic drug usage (e.g., salicylates, antibiotics, NSAIDs).

  2. Notation of urinary output changes.

  3. Evidence of edema or weight gain.

  4. Monitoring mental status changes.

  5. Observation for hematuria.

  6. Detection of dry mucous membranes.

E. Diagnostic Phase Findings in AKI
Oliguric Phase

  1. Increased Blood Urea Nitrogen (BUN) and creatinine levels.

  2. Hyperkalemia (elevated potassium).

  3. Hyponatremia (reduced sodium).

  4. Decreased pH (indicative of acidosis).

  5. Signs of fluid overload (hypervolemia).

  6. High urine specific gravity (>1.020 g/ml).

Diuretic Phase

  1. Decreased fluid volume (hypovolemia).

  2. Hypokalemia (decreased potassium).

  3. Further reduction in sodium levels (hyponatremia).

  4. Low urine specific gravity (<1.020 g/ml).

  5. Normal lab values return during recovery phase.

F. Patient Management During Phases

  • Monitoring fluid intake/output accurately; fluid restrictions may be necessary, especially during the oliguric phase.

  • Documenting daily weights to assess fluid retention.

  • Adjusting nutritional therapy based on degree of catabolism and protein intake (0.6 to 2 g/kg/day).

  • Monitoring laboratory values, especially serum potassium levels exceeding 5 mEq/L. Potassium restrictions may be essential when elevated.

G. Chronic Renal Failure (CRF)

Description: Chronic, progressive, and irreversible destruction of nephrons and glomeruli, leading to uremic symptoms.

H. Assessment Factors for CRF

  1. History of substantial medication usage.

  2. Family history of renal disease.

  3. High blood pressure or uncontrolled hypertension.

  4. Diabetes mellitus.

  5. Signs of edema.

  6. Diminished urinary function (hematuria, proteinuria).

I. Dialysis Considerations for CRF

  • Indications for dialysis emerge as renal function declines, with transplantation serving as an option for some clients.

J. Laboratory Findings

  1. Azotemia (high levels of nitrogen waste products in blood).

  2. Elevated creatinine and BUN levels.

  3. Decreased calcium levels.

  4. Increased levels of phosphorus, magnesium, potassium, and sodium.

  5. Anemia (consistent with kidney dysfunction).

HESI Hint

  • Understanding normal lab ranges and clinical implications of deviations for minerals such as phosphorus, magnesium, potassium, sodium is crucial for nursing.

K. Nursing Management in CRF

  1. Regular monitoring of serum electrolyte levels.

  2. Implement daily weights to assess fluid status.

  3. Strict I&O monitoring.

  4. Monitoring signs of fluid overload (jugular vein distension, edema).

  5. Dietary considerations—low protein, sodium, potassium, phosphate diets to prevent deteriorating renal health.

L. Administration of Medication

  • Administer phosphate binders with meals, as renal clients struggle to excrete phosphates.

Urinary Tract Infections (UTIs)

A. Infection Profile

  • UTIs can affect any part of the urinary system and typically caused by Escherichia coli (E. coli).

B. At-Risk Populations for UTIs

  1. Diabetic patients.

  2. Pregnant women.

  3. Males with prostatic hypertrophy.

  4. Immunocompromised individuals.

  5. Catheterized patients.

  6. Individuals with urinary retention.

  7. Older women, particularly with bladder prolapse.

Review of Renal System Questions

  1. Differentiate between acute renal failure (ARF) and chronic renal failure (CRF).

  2. During the oliguric phase, why is protein restricted?

  3. Identify two nursing interventions for hemodialysis clients.

  4. Explain the purpose of antacids during renal failure management.

  5. List essential TT elements in a teaching plan for recurrent UTIs.

  6. Key nursing interventions for renal calculi.

Cardiovascular Connections to Renal Function

  • Renal perfusion is directly related to cardiovascular output. Decreased cardiac output leads to reduced renal blood flow and urine output, highlighting a potential cardiac issue when urine output drops significantly.