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157 Cards in this Set
- Front
- Back
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GRF Calculation
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(140-age)*(wt. kg)*(0.85 if F)/(72*Cr)
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Normal GRF
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>= 90
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MAP of 142/60
1) 72.4 2) 67.3 3)59.2 |
Answer: 67.3
SBP+2DBP/3 |
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Leading cause of ERSD in US?
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DM & HTN
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What lab value should be assessed before the admin. of Gentamicin? Why?
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Creatinine Clearance
B/C nephrotoxic drug that causes ATN and most common cause of interrenal AKI |
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Wh
What is the most common cause of postrenal failure? |
BPH
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Hyperkalemia will show what EKG changes
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Peaked T=waves
Next step would be to obtain a chem panel |
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Hyponatremia pt. need to be on what precautions?
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Seizures Precautions
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Fatal dysrhythmias on EKGs typically follow what type of lab values?
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Increased Potassium
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Excess urine excretions is defined as...
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diuresis
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What process allows for rapid fluid, urea, Cr removal via vasucalr access. It effectively revmoves K+ but spares most protein.
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Hemodialysis
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What process is the most common form of dialysis that can be utilized during sleep and allows for fewer complications and dietary restrictions. This is also a tx method of choice for DM and Cardiac pt.
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Peritoneal dyalysis
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Prerenal failure is most commonly due to hypovolemia. If a prerenal pt. is septic and hypovolemic why interventions should be anticipated?
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IV NS Bolus
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Renal replacement therapy (RRT) for AKI is commonly indicated for what six reasons
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1. volume overload
2.^K+ 3. Metabolic acidosis (bicar <15) 4. BUN >120 5. AMS 6. Precarditis, pericardial effusion, cardiac temponade |
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what causes postrenal failure...
most common cause.... |
mechanical obstruction;
BPH |
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What causes intrarenal failure
most common cause |
direct tissue damage;
Nephrotoxic drugs (gentamicin) |
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What causes Prerenal failure
Most common cause |
factors external to the kidneys;
Hypovolemia |
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Prerenal failure can often be reversable with what
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Fluid replacement
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What is the key recognizer of Kidney injury
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Hypovolemia
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Destruction of the epithelial cells that can sloth off and block the tubules is commonly caused by nephrotoxic agents (gentamicin)....this is termed as
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Acute tubular Necrosis
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Increased levels of nitrogenous waste in the blood such as urea, nitrogen, and Cr is called
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azotemia.
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Pt that do not respond to drug and dietary interventions for AKI and are deemed critically ill are great candidates
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Continuous Renal Replacement Threapy
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What type of access is needed for hemodyalsis
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AVF
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AVF is located and placed where
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Between the artery and vein of the forearm typically the brachial artery and antecubital vein
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When assessing a pt. with a AVF what are you looking for and what action should be taken if abnormal?
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Thrill is palpated and a bruit is heard
**Report immediately*** |
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When is a AVF recommended to be used
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3 months after insertion
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What should never be done in a fistula arm
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BP or IV access
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The most common complication of a peritoneal dyalysis
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Peritonitis
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Within how many minutes can severe renal ischemia because from impaired kidney perfusion
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45minutes
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The MAP should be greater that what to properly perfuse vital organs
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60
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The final stage of kidney failure is
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End stage kidney disease, where complete loss kidney function is greater than 3 mths GRF <15mL/min
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A GRF of <60 for 3 mths is indicative of
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Chronic Kidney Disease
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Onset of AKI is
Most common cause |
sudden; ATN
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Onset of Chronic Kidney Disease
Common cause |
Gradual over years;
Diabetic nephropathy |
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What lab is most critical to observe to follow kidney function
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Cr
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oliguria typicaly manifest with 1-7days of injury to kidneys Unine OP <____mL/day
*Most common in prerenal failure *Longer phase poor prognosis |
400mL/day
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What exacerbates all AKI
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Hypovolemia
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What should be monitored in the diuresis phase
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Hyponatremia. Hypokalemia, dehydration
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What can be given to temporarly stabilize the myocardium and increase the threshold for dysrhythmias
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Calcium gluconate
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Nursing Dx
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Risk for FVE
Risk Infection Less than body requir. Fatigue r/t anemia |
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Chronic Kidney Disease pt. teaching guidelines
1. Weight ____4lbs 2.________BP 3. Edema 4.Increase fatigue/weakness 5.confusion/lethergy |
1. Weight gain greater than 4lbs
2. Increased BP |
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Hemodyalysis pt. are at risk for
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Hypotension, anemia r/t blood loss
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Cloudy peritoneal effluent is a primary clinical manifestation of
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Peritonitis the most common complication of Peritoneal dialysis
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Who is at risk for cirrhosis
1-men 2-women |
men
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Common causes of Cirrhosis
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-Excess ETOH
-protein malabsorption -Hep C/B (any chronic inflammation) |
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The manifestations of cirrhosis is typically
-sudden or -insidious |
Insidious
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EARLY
S&S of Cirrhosis |
Heavy dull RUQ pain
N/V Fever slight wt. decrease enlarged spleen/liver Bowel changes |
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LATE
S&S of Cirrhosis |
Jaundice (Cannot conjugate * excrete bilirubin)
Spider angiomas (nose, cheeks, upper trunk, shoulders) Palmer erythema Hematologic problems (anemia thrombocyto R/T active enlarged spleen) Risk bleeding R/t cannot produce PT Hyperaldosteronism |
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Complication to Cirrhosis (6)
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1. Portal HTN
2. Esophageal/ Gastric varices 3. Peripheral edema 4. Ascites 5. Hepatorenal snydrome=RF r.t hyperaldosteronism 6. Heptic Encephalopathy |
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What is responsible for varices
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Portal HTN (increase venous pressure)
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Esophageal varices are most life threatening complication due to
-infection -bleeding |
Bleeding bc they do not tolerate pressure well
Bleed due to irratates -alcohol-coarse food-acid refulx-straining |
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Ascites results from
* protein shift r/t portal HTN *Hypoalbuminemia *_____aldosteronism |
*Hyperaldosteronism= ^ H2O & ^ NA
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When portal circulation cannon convert urea and to the kidneys to be excreted ammonia is created. This leads to...
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Hepatic Encephalopathy
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Asterixis is
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Flapping of the hand when the arm is straight
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Liver function Panel
-AST -ALT -Alka. Phos -BILIRUBIN are initially ________due to release damaged liver cells |
Elevated
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Cirrhosis will result in
__________ albumin and total protein |
Decreased
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Biggest risk from liver biopsy is
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Bleeding check PT/INR
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Ascites diet should include
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NA restriction
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Diuretic therapy for cirrhosis (ascites)
name some |
-lasix
-aldactone |
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What should be implemented to relieve ascites for impaired respirations and abdominal discomfort
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paracentesis
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Esophageal varices should be taught to avoid
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NSAIDS, ASA, and coughing
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Long term management of esophageal varices with bleeding include
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-B-Blockers-inderal
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Tx of H. Encephalopathy is
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-lactulose-rid ammonia via feces
-prevent constipation |
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Avoid drugs metabolized through the liver
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acetaminphens
statins thiazied diuretics |
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The primary risk factors for HF include
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-CAD
-Advancing age -HTN |
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HF may be caused by factors that interfere with regulating CO such as
-Preload -Afterload - -HR |
-Myocardial contractility
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The hallmark sign of systolic dysfunction (failure) HF is
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decreased in L ventricular EF
caused by impaired contractility, CMP, increased afterload |
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Diastolic failure is dx by pulm congestion, pulm HTN, ventricular hypertrophy, and NOrmal EF
What is the most common cause |
HTN
results in decreased CO Common women, obese, ^age |
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First mechanism of compensation for HF is SNS activation what hormones does this trigger and what are their effects?
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Norepin. Epi
Increase HR, myocardial contraction, and peripheral constriction |
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The second mechanism of compensation of HF is Neurohormonal Response...what hormones does this trigger and what are their effects?
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RAAS
Renin-Angiotension-Aldosterone system Increase vasocontriction H2O NA retention Decrease Cerebral perfusion=ADH=H20 retention |
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Third mechanism of compensation of HF is dilation.
Describe what this does to the heart |
The muscle fibers of the ventricles dilate to allow increase vol. during diastole to increase CO and BP and perfusion.
*Elastic ability eventually fails |
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Fourth mechanism of compensation of HF is hypertrophy to increase the contractile power of the muscle fibers. Why does cause additional issues?
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Requires more oxygen, poor contractility, has poor CAD, and prone to dysrhythmias
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What is the most common form of HF
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LEFT sided HF
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Left Sided HF manifests as
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Pulmonary congestion and Edema
(anxious, pale, cyanotic, cold/clammy skin, wheezing, coughing, blood tinged sputum |
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Right sided HF typically occurs due to Left sided HF
What are the manifestations of Right sided HF? |
JVD, peripheral edema, hepato/splenomegaly, vascular congestion
Weight gain, Tachycardia, ascites -Fatige, bloating, nausea |
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Most common cause of pulmonary edema
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Acute Left ventricular failure r/t CAD
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Two of the early clinical manifestations of HF are
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-Tachycardia
-Fatigue |
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Pt. that are high risk for HF and asymptomatic are thought to be in which stage of HF
-Class I or Stage A -Class II or Stage B -Class III or stage C -Class IV or stage D |
Class I or Stage A
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Pt. with slight limitations and mechanical risk with no S&S are thought to be in which stage
-Class I or Stage A -Class II or Stage B -Class III or stage C -Class IV or stage D |
Class II or Stage B
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Marked limitations with current S&S of HF
-Class I or Stage A -Class II or Stage B -Class III or stage C -Class IV or stage D |
Class III or stage C
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Inability to carry out normal activity requires specialized interventions
-Class I or Stage A -Class II or Stage B -Class III or stage C -Class IV or stage D |
Class IV or Stage D
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A primary dx study/lab test for HF is
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BNP >100
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Lasix can be administered for HF as a Loop Diuretic what action does this have and what should the nurse keep in mind while admin.
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Lasix IV push slow can cause permenant hearing loss
Decreases preload to increase CO **Monitor HypoKalemia |
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A vasodilator that can be given IV.
-Decreased CO w/o ^o2 and causing dysrhythmias -Given in ED or NON-ICU setting -Does not require titration |
Natrecor/Nesiritide
*Monitor BP for symptomatic hypotension |
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A vasodilator that can be given IV.
-Decreases preload & after load; increases CO, Decreases Pulm. congestion -Requires ICU setting for titration (BP q5-10min) |
Nipride/Nitroprusside
*Complications: hypotension* get PO form faster due to turn to rat poision*Renal Pt. should get off faster |
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This medication is given for ADHF and Pulmonary Edema. Acts as a vasodialtor of systemic & pulmonary. Causes increase gas exchange and decrease pulmonary pressure= decrease dyspnea & anxiety.
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Morphine
*Monitor RR* Does not do well w/kidney problems |
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Digitalis (Positive Inotrope) Increases myocardial contractility and decreases the oxygen consumption. Not recommended for initial tx.
What are complications? |
Pt. at risk for toxicity. Esp older due to metabolism of dig.
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A pt. presents with nausea, vomiting, anorexia, and visual halos. What lab would you request an order for?
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Dig level
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What is the most common cause of digitalis toxicity?
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Hypokalemia due to diuretic and digitalis therapy being used in combination
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What type of nutritional therapy should a pt. HF follow?
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Low NA 2.5g (helps tx. edema)
-teach pt. to read food labels |
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How should the pt. weight themselves?
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-same scale
-same clothes -same time |
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When should a pt. report weight increase?
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-3lbs in 2days
-3-5lbs in 1 week |
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Name 5 nursing dx. for HF
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-EFV
-Impaired gas exchange -Activity Intolerance -Decreased Cardiac Output -Deficient Knowledge |
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What are three things that HF pt. can do for health promotion?
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-Address risk factors (BP control, wt. reduction, smoking cessation)
-PNA vaccine q5y -Flu vaccine q1y |
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A vasodialator commonly given for HF to lower to BNP, PAWP. Also a great alternative because it doesn't requite titration and increases CO w.o increasing o2 demand and causing dysrhythmias
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Natrecor
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Motrin is toxic to which organ
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Kidneys (should be given with caution)
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Why should Zosyn also be given cautiously to renal pt.
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because it's nephrotoxic
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What determines if a vent. pt. gets extubated?
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Assessment and normal ABG
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What is the ninth leading cause of death in US
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Cirrhosis
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Protein eventually converts to ________and poses life threatening problems for Cirrhosis pts
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Ammonia
Causes hepatic encephalopathy |
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Fector Hepaticus
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musty sweet odor, occurs w.encephalopathy
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Hepatorenal syndrome is serious because it causes azotemia, oliguria, and intractable ascites....which utilimately means
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^BP, decrease urine output, and ^ electrolytes
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Pt. with cirrhosis should be assessed for all meds due to liver metabolism....additional care should include what 4 things...
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Rest
B-complex vita avoid alcohol avoid asa, nsaids, acetaminophin |
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Ascites pt. shoud restrict NA and increase what in their diet
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Carbs
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Peritoneovenous shunt is a surgical option for cirrhosis pt. w/ascites that reinfuse fluid via venous system. 4 Complications from this procedure
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1. thrombus formation @ venous tip
2. infection 3. fluid vol. overload 4. DIC |
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Esophageal/ Gastric varices are at risk for bleeding and what other potentially life threatening risk
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Aspiration**stabilize pt. and maintain airway
(Sandrostatin, Beta-Blocker) |
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Tx options for esophageal/gastric varices include
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Endoscopic sclerotherapy and ballon temponade
*may require FFP Vit K, PRBC |
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What is a nonsurgical option for Cirrhosis pt. to have portal venous blood is shunted or redirected
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Transjugular Intrahepatic Portosystemic Shunt (TIPS)
**DOES NOT PROLONG LIFE** |
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3 Nursing Dx for Cirrhosis
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1.Imbal. Nutrition:Less than body requirements
2. Impaired Skin integrity 3. Excess fluid Volume***** |
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What should a cirrhosis pt. do before and after a paracentesis?
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Void to prevent bladder punture before
Sit on side of bed or HIGH FOWLERS *Monitor hypovolemia, Decreased electrolytes, and check dressing for bleeding/leakage |
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Diuretic therapy taken for multiple diseases
*pt. should be monitored for cardiac dysrhythmias |
Due to decreased potassium
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Ballon tamponade (used to stop varices w/cirrhosis) should be explained for function and should be checked for patency.
*What is most common complication and how can it be avoided??? |
Aspiration PNA can be avoided by ensuring the stomach is empty and doing NGT lavage throughout care. This also keeps any blood in the stomach from breaking down to ammonia.
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What five things should be assessed w. Hepatic Encephalopathy
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1. Responsiveness (reflexes, PERRLA, A&O)
2. Hyperflexia, asterixis, cordination 3. F&E balance 4. acid-base balance 5. effectiveness of tx. |
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EF is determined by what dx. test
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Echocardiogram
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What should all HF pt. be dc home with
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ACE inhibitor
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When EF is less that 35%, high pulmonary pressures, and biventricular failure is present the pt. is deemed to have
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Mixed systolic and diastolic failure
*Common in dialated Cardiomyopathy |
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Most prominant manifestation of pulm edema is
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Blood tinged frothy sputum
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Pt with ADHF should be placed in ___________to decrease venous return.
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High Fowlers
**BIPAP is also used to push out fluid |
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HF pt. should be taught what 3 things about drug therapy?
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1. take as prescribed
2. take pulse before med 3. take BP at determined intervals |
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Phosphate is inversely r/t Calcium
Calcium carbonate or ______binds to phosphate in bowel |
Caltrate.
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Chronic Kidney Disease results in decreased activated Vita D. This leads to mineral and bone disorder due to decrease CA levels. Activates PTH release and worsens problem...what are tx. options for this pt.
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Phosphate binders (caltrate)
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Caltrate should be admin. w._______
Complication is_________. |
Meals
Constipation.....take w.stool softner |
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Why should Maalox (Mg containing antacid) not be admin to pt. with Kidney failure bc
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MG is dependent on kidney excretion
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SIRS can be triggered by what 6 triggers
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1-mechanical tissue trauma
2-abscess formation 3-ishemic or necrotic tissue 4-microbrial invasion 5-endotoxin release 6-global perfusion deficits |
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MODS results from SIRS bc when when uncontrolled what occurs
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direct damage to enothelium
hypermetabolism vasodilation= decreased svr |
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When tx SIRS/MODS many abx are used. What should nurses be cautious about?
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Nephrotoxic drugs...(zosyn, gentamycin) could lead to excess organ damage (AKI). **Monitor levels
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MODS/SIRS pt. are at increased risk for what due to decreased GI motility and blood being shunted away?
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ulceration and GI bleed
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The hypermetabolic state created by SIRS/MODS result in
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hyperglycemia & increase insulin resistance
DIC Metabolic acidosis Electrolyte Imbalance |
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What is the most important goal of SIRS/MODS
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Prevent further progression
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The nurses role is critical for **VIGILANT ASSESSMENT and MONITORING** what does collaborative care for MODS include
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1-prevent/tx infection
2-maintain tissue oxygenation 3-nutritional/metabolic support |
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TX/prevention towards infection for MODS is accomplished through
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AGGRESSIVE INFECTION CONTROL
(early debridment, early ambulation, strict asepsis) |
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Maintaining tissue oxygenation towards MODS sometimes has to be accomplished through
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sedation and mechanical ventilation
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Nutritional and metabolic needs towards care for MODS is aimed towards preserving organ preservation. This can be accomplished by
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Early and optimal nutrition**KEEP GUT WORKING**
*Enteral route over parenteral route |
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In MODS/SIRS support for failing organs is primary goal of therapy. What should be implemented for
1-ARDS 2-DIC 3-AKI |
1-aggressive oxygen therapy
2-blood products (FFP, PRBC, Plts) 3-CRRT (better tolerated than hemodialysis) |
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ARDS is ______and________form of acute resp. failure where the alveoliar capillary membrane become damaged and permeable to intravascular fluid
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sudden and progressive
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In ARDS when the alveolar fill w. fluid the s/s are
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dyspnea, hypoxemia, reduced lung compliance, diffuse pulmonary infiltrates
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What is the mortality rate of ARDS
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50%
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ARDS is most commonly caused by ______and is tx with_____
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sepsis; IV abx
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The injury pr exudative phase of ARDS: During the decrease of surfactant and alveolar collapse hyaline membranes being to line the alveoli. What does this contribute to?
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The development of fibrosis and atelectasis
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When atelectasis results in hypoxemia that does not respond to increase O2 this is called
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refractory hypoxemia
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What is the intial s/s of hypoxemia
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increased RR and decreased tidal volume
**RESP ALkalosis**=decrease tissue perfusion |
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Frothy pink sputum=___________=nitro+________+morphine+Nipride drip
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Frothy pink sputum=__PULMONARY EDEMA__=nitro+_LASIX_+morphine+Nipride drip
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Reparative/proliferative phase of ARDS is ______weeks after intial lung injury.
Then s/s are increase inflammatory process(WBC) =________w. ______alveolar tissue |
1-2 weeks;
fibrosis, dense tissue w. thickened alveolar tissue |
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Fibrotic phase of ARDS is ______weeks after lung injury.
Remodeling by_________and fibrous tissue decreases SA for gas exchange. =____________ |
2-3 weeks;
Collagenous; Pulmonary HTN |
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Edema on an CXR does not appear until _______% has fluid content
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30%
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CXR for ARDS is typically seen with ca what
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White out aka infiltrates & pleural effusions
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Complication of ARDS: VAP can be prevented by
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strict infection controle (handwash, sterile sx, frequent mouth/oral care q/shift) Rotate tube q24hrs
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Complication of ARDS: Barotrauma is the rupture of over extended alveoli. This can be minimized by
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Smaller tidal volume and varying amounts of PEEP to minimize O2 requirements.= permissive hypercapnia ^CO2 (maintain pH >7.2
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Complication to ARDS: Stress Ulcers management includes
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Correction of predisposing issue (hypotension, shock, acidosis) by early enternal nutrition
PPI (protonix) |
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Complication of ARDS: Renal failure r/t decreased renal perfusion, hypotension, hypoxemia, hypercapnia,
Also caused from |
Nephrotoxic drugs to tx ARDS infections...Monitor levels....Zosyn Vanc, Gent
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What four things should be planned for in ARDS
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1-Pao2 WNL or baseline on RA
2-saO2 >90% 3- patent airway 4- clear lung sounds |
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ARDS pt should be admin lower concentration of O2 that results in paO2 >______mmHg. Pt at risk for 02 toxicity when exceeds ______% for more than 48hrs
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>60mmHg;
60% |
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Postive Pressure Ventilation PPV : PEEP can commonly be applied to keep pt ________at the end of expiration
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alveolar open; pt. is at risk for decrease BP due to hyperinflation and decreased CO
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ARDS positioning stratagies: PRONE POSITION changes ________and predisposes atelectasis
Nurse should___________** |
pleural pressure
****NEVER LEAVE PT ALONE*** |
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Arterial Catheter provides continuous BP monitoring and ABG drawings. CVP= ^ risk for________
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increased risk for infection
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The PAWP determined through SWAN catheter is kept_______as possible w/o impairing _______to limit pulmonary edema
**Ultimate goal |
as low;
CO ULTIMATE GOAL NOT ADVENTICIOUS BREATH SOUNDS |
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ARDS you want the albumin and protein WNL and the pt at _______body weight
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ideal
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