Renal Failure Ect

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Acute Renal Failure (ARF)
1. Prerenal causes w/the highest mortality rate =

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hypovolemia and hypertension

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➢ renal / intrinsic causes

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• nephrotoxic subs = myoglobulin and hemoglobin
• infectious dse, tubular necrosis, glomerulonephritis, vasculitis
• trauma, tumors, atherosclerosis

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➢ post renal causes

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• enlarged prostate, calculi, invading tumors
• treatment = dialysis, no Foley

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ARF is sudden loss of kidney function

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50% decrease of GFR > oliguria = <400 cc/24 hr

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Acute tubular necrosis

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➢ most frequent cause of ARF
➢ due to NSAIDs and ACE inhibitors

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Oliguric, anuric (non-anuric) phase = where uremic symptoms first appear

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➢ w/ ischemia= occurs during 1st 24 hours
➢ w/ nephrotoxic agents= occurs during 1-7 days

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Increase BUN = 1st symptom of acute non-oliguric phase
➢ other s/s

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• bounding pulse, JVD, HTN,
• Kussmaul breathing = compensatory mechanism to ↑ CO2 excretion

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Diuretic Phase = begins w/ gradual increase in daily urine output

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➢ kidneys are able to excrete waste but not able to concentrate urine
➢ hyponatremia, hypokalemia, dehydration may develop

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most common cause of death during recovery phase of ARF

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infection

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during recovery phase. What is happening

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= ↑ GFR, ↓ BUN, ↓ CREA

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prerenal azotemia

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= ↓ Na < 20 meq

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intrarenal azotemia

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= Na > 40 meq

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azotemia =

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↑ in BUN/ CREA

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. fluid replacement for ARF=

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calculated as % of previous day's urine output + 400cc insensible loss

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10. if Hyperkalemic =

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treat with Kayexalate or retention enema

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Chronic Renal Failure (CRF) / ESRD
11. CRF is irreversible, progressive damage of both kidneys

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= results in uremia / azotemia

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12. 60% of pts on dialysis have ?

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HTN and DM

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13. risk factors =

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DM, HTN, SLE, chronic GN, ARF

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14. GRF is < 10 -20 mm/min =

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need dialysis

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15. if there is high waste products in the body, first changes seen is in =

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mental status

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16. uremic syndrome =

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polyuria leading to anuria

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17. musculoskeletal changes =

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freq. fractures, bone pain, joint and muscle pain

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18. skin changes with CRF =

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pruritus, orange - green color to gray color skin

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➢ Muercke’s line=

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red bands in nails

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➢ uremic frost

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uremic crystal on skin

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Systemic Lupus Erythematous (SLE)
1.is a chronic multi-system inflammatory dse of the connective tissues. It effects

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➢ affects organ systems, joints and lungs

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2. worse during=

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pregnancy, postpartum, onset of menarche, use of oral contraceptives

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3. 40% w/

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butterfly rash across the bridge of nose and cheeks

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4. first complain =

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polyarthralgia with morning stiffness; joint swelling and pain on movement

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5. arthritis can cause ?

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swan neck, ulna deviation

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6. #1 cause of death w/ SLE

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Nephritis

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7. diagnostic work

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= (+) ANA

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8. care during acute exacerbation =

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low Na diet, protect against sun, tx ssx as they occur

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Acute Glomerulonephritis
1. occurs 21 days after

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a strep infection of throat

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2. primary presenting feature =

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hematuria ( rust colored urine), proteinuria

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Acute Glomerulonephritis
3. complications of =

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HTN encephalopathy, ARF w/ oliguria, CHF, ICP, pulmonary edema

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spinal cord injury
1. # 1 cause

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= trauma

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2. flexion dislocation (vertebrae are dislocated)

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= cause the most severe nerve damage

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➢ hyperflexion =

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chin to chest injury

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➢ hyperextension (head is tilted all the way back) =

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pt falls on chin

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➢ axial loading

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= impact to top of head

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➢ penetrating wound =

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gunshot or knife wound that severs the spinal cord

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3. upper cord injury (cervical spine or cord injury)

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= quadriplegia

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➢ lower cord injury (thoracic and lumbar spine injury

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) = paraplegia

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➢ above C4 injury

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y = death => loss of innervation to diaphragm and intercostal muscles

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➢ Ischemia, edema, hemorrhage 2ndary to trauma

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= loss of spine function

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4. complete cord involvement =

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flaccid paralysis (total loss of sensory and motor function)
+ no pain sensation below level of injury

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5. ►Brown-Séquard syndrome

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➢ one-sided motor paralysis on same side of cord injury, loss of touch, pressure, vibration & position sense= same side
➢ loss of pain and temperature sensation = contralateral to injury

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►central cord syndrome (hyperflexion and hyperextension injuries)

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➢ more weakness in the bilateral upper extremities

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6. Spinal shock

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➢ flaccid paralysis below level of injury
➢ body temperature equal to temperature around pt (Poikilothermism)
➢ last 7-10 days but can go for weeks to months

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7. signals end of spinal shock

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➢ spasticity
➢ reflex emptying of the bladder
➢ hyperreflexia (autonomic dysreflexia)
➢ * does not mean return of spinal cord functioning

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8. ►injury above C4

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(total loss of respiratory fx) = require mechanical ventilation

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►injury below C4

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(have diaphragmatic breathing) = cause hypoventilation

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9. cervical fractures

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= unable to cough; risk for atelectasis, aspiration, pneumonia

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10. urinary retention is common with ?

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acute spinal cord injury and spinal shock

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11. injury above T5

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(will develop stress ulcers) = give Prevacid or antacids

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➢ primary problems with injury above T5,6,7

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• ↓ gastric motility
• paralytic ileus
• gastric distention = need NG tube

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12. pulmonary emboli

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= # 1 cause of death for SCI patients

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13. decompression laminectomy =

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# 1 surgical procedure for SCI patients

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14. emergency care focuses on

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➢ maintain airway and breathing
➢ admin of steroids w/in 4 hrs of injury
➢ * Methylprednisolone = improve blood flow and ↓ edema of spinal cord (in 8 hrs)

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15. Quad-assist coughing =

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stimulates the action of the ineffective abdominal muscles during expiratory phase of coughing

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16. interventions for cardiovascular dysfunction =

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ROM exercises and heel stretching
➢ "atropine" = to bring HR up
➢ "dopamine" = to treat drop in BP

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other interventions for SCI
➢ nutrition =

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high protein, high carbohydrates, high fiber diet

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➢ bowel management

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= use of laxatives and suppositories > no enemas

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➢ temperature control

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= avoid over dressing and over exposing
= w/ fever > give cooling blanket

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➢ to treat spasms

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= warm compresses; whirlpool baths; antispasmodics

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17. Autonomic Dysreflexia (hyperreflexia)

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➢ a syndrome characterized by abrupt high blood pressure of >200/100

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➢ injuries to T5 - T6 and above are greatest risk

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for Automatic Dysreflexia

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18. Intact ANS below the level of lesion respond to stimulation with

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➢ Reflex Arteriolar Vasoconstriction => increase in BP
➢ Baroreceptors in carotid sinus and the aorta sense the increase in BP and stimulate the Parasympathetic Nervous System => decrease in HR (< 60)

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19. Clinical Manifestation of Autonomic Dysreflexia

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➢ BP > 200/100, HR < 60
➢ pounding headache
➢ above injury = flushed face, sweating, nasal stuffiness
➢ below injury = piloerection (goose bumps),skin cold and clammy

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20. treatment for autonomic dysreflexia (hyperreflexia)

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➢ elevate HOB to 45 degrees
➢ irrigate catheter to restore patency
➢ if prone to AD > Clonidine / Minipress
➢ to prevent AD
• do not wear tight clothing
• position changes q 15 mins
➢ home management
• properly fitted wheelchair
• no arm movement = high back and head support
• can use arms = back of chair should reach level of scapula
• have gel-foam cushions and taught to shift weight q 15 mins

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21. Dysesthetic pain (chronic phantom pain)

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= disabling pain distal to site of injury

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22. Upper Motor Neuron

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➢ T12 and above = spastic / reflex bladder
➢ T10 - L1 and above = reflex erection, no ejaculation

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Lower Motor Neuron

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➢ lumbar/sacral - T13 and below) = flaccid bladder
➢ L2 - S4 and below
• reflex erection by touch, no ejaculation
• can father a child

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Addisons/Cushings

1. What causes Addison’s disease?

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➢ ↓ mineralocorticoids/glucocorticoids/androgens

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2. What are symptoms of Addison’s?

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➢ chronic, steadily increasing fatigue
➢ craving for salty foods
➢ tanned appearance

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3. What is the most reliable test for Addison’s?

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➢ ACTH stimulation test: give IV corticotropin= ↑ is ok, ↓ is Addison’s

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4. What do you teach your patient when experiencing excessive sweating?

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➢ Increase Na intake

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5. What are the clinical manifestations of Cushing’s?

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➢ Wt gain in the abdomen w/ thin extremities (due to muscle wasting)
➢ Moon face, red cheeks, and acne
➢ Buffalo hump ( fat deposit in back of neck/shoulders

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6. What is a diagnostic test for Cushing’s?

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➢ Low dose dexamethasone suppression test

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7. What medical procedure will increase risk for addisonian crisis?

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➢ B/L adrenalectomy (removal of pituitary tumor)