Hubs 2nd Exam

Urinary System

 

Urinary Tract Obstruction

Obstruction of urinary flow occurring anywhere from renal calyces to the urethra and can be anatomical of functional

Caused by…

  • Kidney/Renal stones

  • Compression from other structures eg tumours

  • Narrowing of tract

  • Vesicoureteral reflux (urine backflow into urethra)

  • Prostatic Hypertrophy (compresses urethra)

 

Pathophysiology of a urinary tract obstruction is it results in tract proximal to obstruction and the accumulation of urine. Backup causes damage to distal nephron, proximal nephron and glomeruli which causes damage and reduction in the kidney tissue and can lead to decreased GFR (glomera filtration rate), decreased reabsorption and urine concentration and decreased secretion

 

Signs & Symptoms

Renal Collic - Spasm of smooth muscle

  • Pain

  • Nausea & vomiting

  • Blood in urine

 

Pyelonephiritis - Bacterial Infection of the kidney

  • Pain

  • More likely to develop kidney stones

  • Cloudy urine

  • Frequent and urgent need to urinate

  • Fever and chills

  • Flank & groin pain

 

 

Acute Kidney Injury

Acute kidney injury is a sudden decline in kidney function occuring over hours to days that inhibits the ability to regulate fluid, electrolyte and acid base balance

Caused by…

  • Decreased GFR

  • Elevated serum creatinine

  • Oliguria

  • Blood urea nitrogen elevation

 

3 Types of Acute Kidney Injury

  • Prerenal

  • Intrarenal

  • Postrenal

 

Prerenal - Impairments in renal blood flow and fluid backing up

Occurs before blood gets to kidney and is the most common type of AKI

Caused by; hypovolemia, haemorrhage, hypotension, severe burns, cardiac dysfunction, septic shock, renal artery stenosis or clamping

 

 

Intrarenal - Due to abnormalities within the kidney

Caused by; interstitial nephritis, acute tubular necrosis, glomerulonephritis, vascular disease, tumours/cancer and polycystic kidney disease

 

Acute Tubular Necrosis - Something causes damage to the nephrons and cells of nephrons causing them to die. Can be caused by prerenal causes due to lack of blood and nutrient supply to the nephrons and cause nephron ischemia and cells to die but other causes include medicines, toxins, blood clots, pyelonephritis (kidney infection)

Glomerulonephritis - Inflammation of the glomerulus

Caused by diabetic neuropathy, antigen-antibody complexes, autoimmune reactions, toxins and drugs

Symptoms

  • Oliguria

  • Oedema

  • Dyspnoea

  • Nausea and vomiting

  • Confusion

  • Irregular heart rhythm

  • Coma

  • Death

 

Management

  • Find and treat underlying cause

  • Balance fluid

  • Control potassium and calcium levels

  • Possible dialysis

 

 

 

Chronic Kidney Disease

Chronic kidney disease is the long term progression and irreversible destruction of the nephrons

Common causes…

  • Diabetes

  • Hypertension

  • Unresolved AKI

 

Symptoms

  • Oedema

  • Dehydration and fluid overload

  • Azotaemia (urea back up in blood)

  • Build up of Acid, sodium and potassium

  • Anaemia

  • Uraemia

  • Nausea and vomiting

  • Anorexia

  • Diarrhoea

  • Peripheral neuropathy

  • Pericarditis

  • Hypertension

  • Muscle wasting and bone pain

 

Management

  • Dietary control

  • Erythropoietin supplementation

  • ACE inhibitors or receptor blockers

  • Hyperglycemic control and insulin

  • Dialysis

  • Renal transplant

 

 

 

 

 

 

 

 

Obesity

Obesity is excess adipose tissue mass

 

Obesity Measurements…

  • Body Mass Index (BMI) is weight/height 2 (kg/m2)
    Healthy is 18-25, overweight is 25-30, obesity is 30+

  • Anthropomorphic Measurement uses waist circumference, skin fold thickness and waist to hip ratio

  • Water weighing is weighing underwater

  • Scans eg. CT, MRI & DEXA (gold standard but very expensive)

 

Respiratory Complications with Obesity

Obstructive sleep apnoea due to increase in abdominal mass pressure against diaphragm. Asthma has been associated with obesity

 

Causes of Obesity…

  • Leptin gene alterations

  • Prader-willi syndrome

  • PCOS

  • Cushings

  • Hypothyroidism

 

Risk Factors…

  • Sedentary lifestyle

  • Poor diet

  • Stress

 

 

Management…

  • Weight loss

  • Dietary changes

  • Increase exercise

  • Behavioural therapy

  • Pharmacological therapy

  • Surgery (gastric banding or gastric bypass)

Burns

 

Superficial Burns

Epidermis, nerve endings exposed, very painful, heals rapidly in 7-10 days, pink colour, capillary refill and sensation and hairs present

 

Partial Thickness/Deep Dermal

Dermis, nerve endings exposed, hair follicles and sweat glands possibly involved, extremely painful, 3+ weeks to heal, lots of pain relief, may require skin graft, blisters, red or white colour, capillary refill slow or absent, few hairs and will require extensive dressing changes

 

Full Thickness

Very deep burns, no pain due to nerve endings being destroyed, requires excision and grafting, very long time to heal, significant scarring, could be white, tan, black dry and leathery, no capillary refill, sensation or hairs

 

Local Effects of Burns…

  • Pain

  • Vasodilation

  • Increased capillary permeability with loss of albumin in ISS

  • Loss of fluid and electrolytes into ISS and environment

  • Loss of heat due to conduction and evaporation

  • Loss of protective skin barrier

 

 

Systemic Effects of Burns…

  • Hypovolaemia

  • Stress ulceration

  • Bone marrow suppression

  • Immune response to burn

  • Widespread body changes

  • Loss of GIT barrier function

  • Hypermetability of capillaries

  • Hypermetabolic state

  • Heat induced denaturing of collagen fibres

  • Suppression of insulin, growth hormone and anabolic steroids

 

 

Fluid Resuscitation

Fluid resuscitation time is calculated from the time of burn injury, burn extent and is measured by urine output

Lactated Ringers is the fluid of choice and will perfuse the kidneys so they will produce enough urine

Parkland Formula is the formula used in fluid resuscitation and end point with urine output is

Adults 0.5 - 1.0mL/kg/hr

Children 1.0 - 1.5mL/kg/hr

 

 

 

 

 

Endocrine System

 

Hyperthyroidism - Excessive thyroid hormone (TH) production and secretion

 

Causes…

  • Graves disease (most common)

  • Thyroiditis

  • Tumour

  • Overcompensating for puberty or pregnancy

 

Symptoms…

  • Goitre (swelling of thyroid)

  • Tachycardia

  • Palpitations

  • Hypertension

  • Exophthalmos (bulging eyes)

  • Anorexia

  • Insomnia

  • Tremor

  • Thyrotoxic Crisis can lead to death

 

Treatment…

  • PTU oral meds

  • Propanolol

  • Radioactive iodine

  • Surgical removal of the thyroid

 

More receptors on cells for sympathetic nervous system causes a lot of the symptoms

Graves disease produces antibodies to the thyroid gland which bind receptors that cause the release and production of TH

 

 

Cushing Disease (Hypercortisolism) - Chronic excessive levels of cortisol

Causes…

  • Tumour

  • Steroid Use

 

Symptoms…

  • Hyperglycemia

  • Polyuria

  • Quick adipose accumulation (moon face, buffalo hump, truncal obesity)

  • Protein wasting

  • Muscle Weakness

  • Muscle loss in arms and legs

  • Stretch marks and brusing

  • Hypertension

  • Immunosuppression

  • Poor wound healing

 

Treatment…

  • Dexamethasone

  • Surgery if from tumours

  • Titrate off steroids slowly if from steroid use

 

 

 

 

IV Fluids

Hypotonic - Less concentrated compared to plasma, water moves from ECF to ICF through osmosis

Isotonic - Matches plasma concentration, equal water transport from ECF and ICF

Hypertonic - More concentrated compared to plasma, water transported out of ICF to ECF

 

Hypovolaemia - Deficient fluid volume in ECF

Signs & Symptoms…

  • Hypotension

  • Tachycardia

  • Decreased skin turgor

  • Dry mucosae

  • Oliguria

  • Organ Failure

  • Hypovolemic shock

 

Treatment…

  • Replace water and electrolytes with balanced IV solution

 

 

Hypervolemia - Excess fluid volume in ECF

Signs and symptoms…

  • Hypertension

  • Tachycardia

  • Oedema

  • Pleural effusions

  • Pulmonary oedema

  • Ascites

  • Organ failure

  • Impaired gas exchange

 

Treatment…

  • Remove fluid without changing electrolyte composition or osmolarity of ECF

 

Nursing Management for Hypovolemia and Hypervolemia

  • Fluid balance chart

  • Monitor cardiovascular changes

  • Monitor Respiratory changes

  • Monitor neurological changes

  • Daily weights

  • Skin assessment

  • IV therapy

 

 

 

 

 

 

Alcohol

Metabolism

  1. Alcohol dehydrogenase enzyme metabolizes alcohol into acealdehyde

  2. Acetaldehyde breaks down into acetate

  3. Acetate broken down into CO2 & H2O to be eliminated from the body

 

Withdrawal

Involves the limbic system and response of the autonomic verous system. CIWA (withdrawal assessment)

 

Mild withdrawal Symptoms…

  • Nausea & vomiting

  • Headaches, photo sensitivity

  • Tachycardia

  • Hypertension

  • Tremor

  • Insomnia

  • Anxiety

 

 

Severe Withdrawal…

  • Complete confusion

  • Physical Agitation

  • Hallucinations

  • Fever

  • Tachycardia

  • Hypertension

  • Diaphoresis (excessive sweating)

  • Can lead to collapse or death

 

Management…

  • IV Fluids to replace electrolytes, fluid and glucose

  • Benxodiazepines

  • Antabuse

  • Alcohol itself

 

 

 

 

 

 

Acid-Base Balance & Electrolytes

 

Respiratory Acidosis - pH below 7.35, breathing related, reduced breathing or trapping of CO2

Causes…

  • COPD

  • Medications that decrease RR

  • Brain Injury

  • Lung Diseases (pneumonia, heart failure, asthma, bronchitis)

  • Rib fracture stops deep breathing

  • Paralysis

 

Symptoms…

  • Headache

  • Blurred vision

  • Twitch

  • Tremor

  • Convulsion

  • Coma

 

 

Respiratory Alkalosis - pH below 7.45, increased breathing/hyperventilation

Causes…

  • Anxiety

  • High metabolic rates (fever, sepsis)

  • Head injuries

  • Excessive mechanical ventilation

  • Pain

 

Symptoms…

  • Dizziness

  • Tingling

  • Confusion

  • Convulsions

  • Coma

 

 

 

Metabolic Acidosis - pH below 7.35, body producing to much acid or kidneys not working to excrete enough

Causes…

  • Diabetic Ketoacidosis (DKA)

  • Renal Failure

  • Lactic Acid Production

  • Severe Diarrhoea

 

Symptoms…

  • Kussumaul Respirations

  • Nausea & Vomiting

  • Anorexia

  • Arrhythmia

  • Hypotension

  • Death

 

 

 

Metabolic Alkalosis - pH above 7.45, body/kidney getting rid of too much acid

Causes…

  • Severe vomiting

  • Overtreatment of Acidosis

  • Loop & thiazide diuretics

  • Hyperaldosteronism

 

Symptoms…

  • Hyperactive reflexes

  • Cramping

  • Tetany

  • Atrial tachycardia

  • Convulsions

 

 

 

 

Hypernatremia - Increased sodium levels in blood above 145mmol/L

Water loss - Dehydration from fever, decreased thirst, increased urination, diarrhoea

Sodium gain - Hyperaldosteronism, diabetes inspidus, sline or bicarb fluids, kidney disease

 

Symptoms…

  • Increased thirst

  • Dry mucous membranes

  • CNS cellular dysfunction

  • Lethargy

  • Irritability

  • Muscle twitching

  • Seizures

  • Coma

  • Fever

  • Hypertension

  • Pitting oedema

  • Weight gain

 

 

 

 

 

 

Shock

Shock - Occurs when the cardiovascular system fails t perfuse the tissues adequately, resulting in widespread impairment of cellular metabolism

 

Types of Shock

  • Cardiogenic Shock; Heart fails as a pump

  • Hypovolemic Shock; Not enough circulatory fluid to pump

  • Neurogenic Shock; Damage to nervous system

  • Anaphylactic Shock; Allergic reaction

  • Septic Shock; Infection

 

 

Stages of Shock

Stage 1 - Initial; Hypoxia and systemic acidosis begins

Stage 2 - Compensating; Mechanisms initiated to try and reverse condition. Increased HR and BGL, decreased BP, urinary output and bowel sounds, pale, nausea & vomiting

Stage 3 - Decompensating; Cause of crisis not treated causes compensatory mechanisms to fail

Stage 4 - Refractory; Vital organs have failed and shock can no longer be reversed. Brain damage and cell death is occurring so death will follow

 

 

 

Distributive Shock - Distribution of blood problem (includes septic shock, anaphylactic shock and neurogenic shock)

Septic Shock; Infection

Signs & Symptoms…

  • Temp isntability

  • Tachycardia

  • Increased RR

  • Hypoxemia

  • Increased WBC count

  • Oliguria and renal dysfunction

  • Confusion

  • Respiratory Distress

 

Management…

  • Antimicrobial therapy and control of infection source

  • Fluid resuscitation

  • Inotropes

  • Vasopressors

  • Cardiorespiratory support

  • Ventilation

 

Anaphylactic Shock; Allergic Reaction

Signs & Symptoms…

  • Airway constriction

  • Peripheral ooedema

  • Swelling lips, tongue and throat

  • Hives and itching

  • Headache and LOC

  • Abdominal cramps

 

Management…

  • Removing allergen

  • IM adrenaline

  • Fluid management

  • Antihistamines

  • Corticosteroids

 

Neurogenic Shock; Damage to nervous system and wide spread vasodilation

Signs & Symptoms…

  • Low BP

  • Bradycardia

  • Decrease CO

  • Hypotension

 

Management…

  • Fluid management

  • Vasopressors