Renal and Urinary Conditions

• BUN to Creatinine ratio of 25:1 indicates pre and postrenal issues

Hemolytic Uremic Syndrome

• Typically stems from E. coli infection
• Management includes blood transfusions for anemia, monitoring dehydration, fluid and electrolyte balance, and renal dialysis if necessary

Pyelonephritis

• Initiate empirical antibiotics
• Treatment should start while awaiting culture and sensitivity results

Nephrotic Syndrome

• Proteinuria greater than 3.5 g/L in a 24-hour urine collection characterizes it
• Manifestations include proteinuria, hypoalbuminemia, hyperlipidemia, and edema
• Dietary modifications for patients with significant edema consist of a high-protein, low-sodium diet
• CKD is a common complication

Pyelonephritis Diagnosis

• Expect vomiting, flank pain, fever, and chills

Recurrent UTIs

• Prescribed antibiotics can lead to potential fungal infections

Dietary Management for Nephrotic Syndrome

• Limit protein intake if kidney function is severely impaired
• Restrict fluid intake if edema is significant

Acute Kidney Injury

• Risk factors include age >65, HF, and nephrotoxic medications like iodine, NSAIDs, ACEI, cocaine, heroin, and herbal remedies

Prerenal AKI

• Involves no direct damage to kidney tissues
• Caused by decreased renal perfusion and a drop in GFR, resulting from reduced blood flow to the kidneys
• Common causes: hemorrhage, burns, HF, dehydration, vasodilation, and GI losses
• Labs: BUN: Creatinine >20:1 and low urine sodium (<20 mEq/L)
• Increased levels of urea and other nitrogen compounds in the blood are present
• Interventions: IV fluids to restore perfusion, monitoring urine output, and avoiding nephrotoxins
• Hypovolemia may result from vomiting and diarrhea, which reduces circulating blood volume and renal perfusion

Intrarenal AKI

• Direct damage to nephron structures leads to impaired reabsorption and filtration within the kidneys
• Most likely causes: infection, nephrotoxic medications, or physical trauma
• ATN (Acute Tubular Necrosis) is the most common cause of intrarenal AKI in hospitalized patients
• Muddy brown casts, protein, and a fixed specific gravity are present

AKI Education/Interventions

• Educate on hydration before and after contrast use
• Avoid nephrotoxins
• Hold Metformin, if applicable

AKI: Exposure to Contrast Media

• It may cause direct tubular injury (ATN)
• A client receiving IV contrast for a CT scan may develop oliguria and rising BUN & Creatinine 48 hours later

Postrenal AKI

• Mechanical obstruction increases hydrostatic pressure in the tubules, reducing GFR when urine can't flow out
• Obstruction, such as BPH or kidney stones, causes urine backup, increasing pressure and impairing function
• Monitor with a foley catheter for return of urine and notify the provider;
• Goal: improved output, decreasing BUN/Creatinine, resolving symptoms
• Early stages may present with normal urinalysis; if untreated, it can lead to intrarenal damage; bilateral obstruction causes hydronephrosis

AKI Phases

• Goal: improved output, decreasing BUN/Cr, resolving symptoms

Oliguric Phase (10-14 days)

• Urine output < 400 mL/day
• Fluid volume overload
• Electrolyte imbalance (hyperkalemia and hyponatremia)
• Metabolic acidosis
• Elevated BUN (>20) and Creatinine (>1.2)
• Decreased GFR (<90)
• Elevated specific gravity (>1.030)

Diuretic Phase (1-3 weeks)

• Osmotic diuresis, urine output up to 5L/day
• Hypovolemia
• Hypotension
• Hypokalemia (bradycardia and decreased LOC)
• May experience type 1-3 cardiac blocks
• BUN and Creatinine start to normalize

Recovery Phase (Months-Years)

• GFR increases
• BUN and Creatinine levels plateau then decrease
• Decreased edema
• Normalization of fluid/electrolyte balance
• Labs will be normal

AKI Labs

Normal

• GFR: >/= 90 mL/min
• BUN: 7-20 mg/dL
• Creatinine: 0.6-1.2 mg/dL
• BUN/Creatinine: 10-15:1
• Urine Sodium: 20-40 mEq/L
• FeNa: 1-2%
• Serum Sodium: 135-145 mEq/L
• Serum Potassium: 3.5-5.0 mEq/L

Prerenal

• GFR: decreased (low perfusion)
• BUN and Creatinine: elevated
• BUN/Creatinine ratio: >20:1, high BUN
• Urine Sodium: <20 mEq/L, low (retained)
• FeNa: <1%, low
• Serum Sodium: normal or high (volume depletion)
• Serum Potassium: normal or mildly high

Intrarenal

• GFR: decreased (nephron damage)
• BUN and Creatinine: elevated
• BUN/Creatinine: </= 15:1 (both rise proportionally)
• Urine Sodium: >40 mEq/L, high (sodium wasting)
• FeNa: >2%, high
• Serum Sodium: normal or low (dilutional)
• Serum Potassium: elevated (excretion)

Postrenal

• GFR: decreased (obstruction/backpressure)
• BUN and Creatinine: elevated, variable
• BUN/Creatinine: variable... may be >20:1 (high) early, then low
• Urine Sodium: variable (low early, high later)
• FeNa: Variable
• Serum Sodium: Variable (often normal or low)
• Serum Potassium: elevated (especially with prolonged obstruction)

AKI Diagnostics

20:1 BUN:Creatinine Ratio

• Suggests prerenal AKI – the kidneys conserve creatinine while urea rises with hypovolemia

Muddy Brown Casts

• Indicative of acute tubular necrosis common in intrarenal AKI.

Elevated Creatinine with Normal Urinalysis

• May suggest early postrenal obstruction or prerenal without tubular damage.

Decreased GFR with Normal BUN

• Possible chronic kidney disease or early AKI.

AKI Key Points

• Renal ultrasound is the first-line imaging
• KUB x-ray, CT urogram
• FeNa <1% in prerenal, >2% in ATN
• Assess for urine sediment and casts.

Dialysis

Hemodialysis (HD)

• Removes waste quickly
• Used in both AKI and CKD
• Requires vascular access
• Rapid fluid shifts may cause hypotension
• Intermittent 3-4 hr runs
• At hospital or dialysis center

Peritoneal Dialysis (PD)

• Intermittent over 3-4 hr
• Instill dialysate into peritoneal space and drain after sitting for 3-4 hr
• Draining takes about 10 minutes
• Can be done at home
• Uses peritoneal membrane
• Risk for peritonitis and protein loss
• Have to be stable

PD Risks

• Peritonitis with a Rigid Board-Like Abdomen, acute abdominal pain, distention, fever, shallowing breathing d/t pain (and diaphragmatic pressure), altered mental status, shock
• Abdominal Compartment Syndrome (abdominal HTN that restricts ventilation and can lead to respiratory failure; high pressure in the abdomen and decreased Cardiac output can lead to AKI and inflammation of other organs such as the pancreas and liver)
• Hyperglycemia

CRRT

• Ideal for unstable ICU clients
• Continuous filtration prevents hypotension and allows gentle fluid/electrolyte correction
• Used until no longer needing it.

Dialysis Indications

• Volume overload, hyperkalemia, acidosis, BUN >120, toxins, pericarditis, encephalopathy. AEIOU mnemonic
• A: Acidosis
• E: Electrolyte Imbalances (hyperkalemia)
• I: Intoxicants (ingestion or overdose of medications/drugs)
• O: Overload of fluid (causing HF)
• U: Uremia (urine in blood-leads to encephalitis/pericarditis →infections)
• CRRT is best for unstable clients due to gradual solute/fluid removal

Urinary Tract Infections

• Infection anywhere in the urinary tract
• Manifestations: dysuria, frequency, urgency, cloudy urine

Pyelonephritis/ Kidney Infection

• UTI that specifically affects the kidneys
• Manifestations: fever, chills, N/V, flank pain (costavertebral angle tenderness)
• Hallmark signs= flank pain and N/V

Glomerulonephritis –STREP

• Patho: a kidney condition that involves damage/inflammation to the glomeruli leading to “leaking" of RBCs leading to mild protein in urine
• Less protein in urine and tea colored urine

Glomerulonephritis - Strep causes

• Immune system creates an antigen antibody complex inflamed glomeruli.
• Post strep infection (positive ASO titer) – 14 days post infection – Pediatric 2 -10yrs old
  • HTN
  • Antigen ASO titer
  • Decreased GFR (decr Urine)
  • Swelling face (edema)
  • Tea colored urine
  • Recent strep
  • Elevated labs (incr BUN and Cr)
  • Proteinuria (mild)

Glomerulonephritis - Strep Care

• Monitor vitals + Blood Pressure
• Administer Anti-HTN and Diuretics
• Monitor I's&O's and Potassium

Glomerulonephritis - Strep Etiology

• Relapse not common
• Teach to monitor child for sore throat- strep
• Etiology, R/F, causes:
  • Streptococcal infection of the throat (strep throat) or skin (impetigo)
  • Hereditary diseases
  • Immune diseases such as SLE
  • Diabetes
  • HTN
  • Vasculitis (inflammation of the blood vessels)
  • Viruses (HIV, Hep B, and Hep C)
  • Endocarditis (infection of the heart valves)

Glomerulonephritis - Strep Manifestations

• Diluted tea color urine, Foamy Urine
• Flank pain (back/vertebral pain)
• Hematuria a lot/visible to naked eye
• Oliguria, Dysuria

Glomerulonephritis - Strep Treatment

• Treat underlying cause
• Controlling BP is most important with Dialysis, Medications, and Diuretics
• Immunosuppressants (not typical)
• Antihypertensive's (CCB or ACE inhibitors: Beta blockers not good for children)
• Sodium and water restriction
• Potassium, phosphorus, magnesium restriction
• Take calcium supplements
• Maintain a healthy weight through diet and exercise
• Physiotherapy tx: Breathing exercise, endurance training, Lymphatic massage to reduce edema

Glomerulonephritis - Strep Complications

• Acute kidney failure/CKD, nephrotic syndrome, electrolyte imbalances, pulmonary edema, CHF d/t fluid overload

Hemolytic Uremic Syndrome- Patho/Causes

• Patho: Triad→ hemolytic anemia, thrombocytopenia, acute kidney injury (d/t damage to small blood vessels in the kidneys)
• Causes: Typical: most common infection with STEC (shiga toxin-producing e.coli) or Atypical: genetic or r/t immune system problems

Hemolytic Uremic Syndrome - Sx

• Bloody diarrhea
• Abd pain
• Vomiting
• Progresses to: pale skin or jaundice, bruising or petechiae, decreased urine output, swelling

Hemolytic Uremic Syndrome - Nursing Management

• Supportive care with Fluids, BP regulation, acid/base balance, blood transfusions, and kidney support (dialysis, if needed)
• Avoid antibiotics and administer Eculizumab
  • Immunosuppressive medication that causes an increased risk for meningococcal infection, so a vaccine is recommended

Nephrotic Syndrome

• Patho: Increased glomerular permeability, loss of plasma proteins (albumin), reduced plasma oncotic pressure, edema; reduced oncotic pressure is caused by hypoproteinemia (low plasma protein levels, especially albumin) leading to fluid shifting from the blood vessels into the surrounding tissues, edema (swelling), and fluid leaving blood vessels and going into surrounding tissues

Nephrotic Syndrome: Sx and Causes

• Hallmark symptom: Lots of protein in urine (proteinuria), that's dark and frothy (tea/ cola color); Proteinuria, hypoalbuminemia, hyperlipidemia, oedema (around eyes, legs, labia = Anasarca = Massive edema) = SWOLLEN CHILD
• Cause: Congenital, primary or idiopathic, secondary; unknown changes to glomeruli (other causes = SLE, DM, HF = peds 2:10); Low ASO titer (not caused by Strep)

Nephrotic Syndrome: Nursing Care/Management

• Monitor I's&O's, fluid state, diuretics, IV albumin, and Corticosteroids
• Medical Management: Diet = decrease sodium, fluids and protein; Steroid therapy (ie prednisone) at least 4-6 wks
• Prevent gastric complication w Antacid
• Antibiotic therapy and Diuretics (Furosemide or Spironolactone) are indicated; as well as Potassium Supplement
• manage massive edema and Colloids-- Maybe blood transfusion or plasma depending on hypoalbuminemia
• Immunosuppressant drugs ie methotrexate; Diet: high protein, low sodium (protein rich is advanced dx, sodium restricted esp, needs a water restriction, high calorie, carb, and protein = mindful w low fats elevated trygl)

Burn Injuries

Burn Degree and type

• Superficial partial thickness (first degree) = epidermis and portion of the dermis may be injured = blisters are wet, blanching erythema +red and blanchable with swelling over 24 hrs
• Deep partial thickness (second degree) = epidermis and dermis = fluid filled vesicles red shiny and possibly wet, severe pain, and edema, starting to affects nerves and resulting in loss of sensation
• Full thickness (third degree) = destruction of all skin elements and local nerve endings; coagulation necrosis present, requires surgery =Dry, waxy, white or black/brown charred leather hard skin that is insensitive to pain

Burn Manifestations

• High potassium– cells are getting destroyed and potassium is getting released to be circulating in the blood- give calcium gluconate first to lower potassium and stabilize heart membrane
• Hypovolemia, decreased CO, edema, decreased circulating blood volume, hyponatremia, hyperkalemia, hypothermia

Burn Management

• Warm room (80-85F- prevent heat loss)
• Provide warm IVF and blood product
• Minimize exposure
• Cool guard should be provided, use of lighting

Burn: other

• Early fluid resuscitation required for burns >20% of body surface
• Potential Complications: acute respiratory failure, distributive shock, acute renal failure, compartment syndrome

Burn Tx

• Escharotomy- used to tx full thickness burns by creating incisions performed to release pressure, facilitate circulation, to allow healing
• Skin grafting- remove healthy skin from one area of the body and moving it to a different place on the body
• Preventing Contractures: PT and OT to achieve full ROM and psychological/psychiatric referral for help coping+ stretching exercises; pressure garment
• Estimating TBSA (Rule of 9's) adds up to 100%
  • Head = 9%
    • Ant./ Post. = 4.5% each
  • Arms = 18% combined
    • L ant./post. R ant./post. = 4.5% each
  • Anterior Chest + Abdomen = 18%
  • Ant. Chest = 9%
  • Ant. Abdomen/belly = 9%
  • Posterior Chest + Abdomen = 18%
    • Post. Chest = 9%
    • Post. Abdomen/belly = 9%
  • Legs = 36% combined
    • L ant./post. R ant./post. = 9% each
  • Groin = 1%

Burn: Fluid/ resuscitation

• 4ml x kg of body weight x % of body burned, with ½ of Parkland Formula in first 8 hrs, then ¼ in the next 8hrs and then last ¼ in the last 8 hr

Appendicitis

• Patho: Caused by Luminal blockage in the appendix = distention and venous engorgement with the buildup of bacteria/mucuous can lead to gangrene perforation and peritonitis
• s/sx, dull periumbilical that leads to RLQ (McBurney's Point), N/V, anorexia, low grade fever, and the present of rebound tenderness and guarding (Positive Rovsing sign)

Appendicitis: Tx

• Laparoscopic or open appendectomy procedure
• Antibiotics and IVF started before surgery
  • IF ruptured or shows sings of peritonitis, give IVF and Antibiotics 6-8hrs to help reduce likelihood of dehydration and sepsis

Bowel Obstructions

• Simple obstruction: allows blood supply
• Strangulated obstruction: cuts of blood supply=accumulation of fluids/gas leads to distention

Bowel Obstructions: Patho

• Increased intraluminal pressure from the proximal distention that leads to ischemia and perforation with risk of sepsis and hypovolemic shock

Small Bowel Obstuction: Sx/manifestations

• Colicky pain, vomiting (bilious), no stool

Small Bowel Obstuction: S/SX exam

• Examination should include checking the bladder, laying the pt supine, checking abdominal symmetry, Ascultate, Percussion, and Palpate

Bowel Obstruction: Large

• often cancer
• cramping, distention, obstipation (chronic constipation that is characterized by the inability to pass stool despite a strong urge), late vomiting; signs of dehydration and sepsis

Bowel Obstruction Tx

• NPO, NG tube (for decompression), bowel rest, IVF and elyte correction, or surgery.

WEEK 9

Cleft Lip

• Repair in 3-6 months.
• Feed with bottle that has a special nipple with a wider base. Squeeze cheeks together to create a tighter seal
• Avoid pacifiers and let child sit in an upright position. Use petroleum jelly and elbow immobilizers to avoid interaction w the site

Cleft Palate

• Repair in 9-12 months.
• Feed w the upright position with one way flow to alleviate air
• Avoid pacifier and elbow immobilizers to avoid interaction with the site and sit in the upright position

Pyloric Stenosis

Pyloric Stenosis : Patho

• Muscle at the outlet of the the stomach (pylorus) thickens and narrows which results in the blockage that does not allow the intestine to be passed down or digested

Pyloric Stenosis : Sx, Manifestations

• Projectile Nonbilious Vomit (often after eating)
• RUQ mass and constant hunger
• Changes in BM- Constipation, Dehydration, Weight Loss, Metabolic Alkalosis

Iintussusception:

Intussusception: Patho

• Telescopes one part in the bowel to another, causing a blockage that can lead to strangulation of bowels that results in gangrene, sepsis, shock, and death

Intussusception: Sx, Manisetations

• Abdominal pain, Currant Jelly Stool- Blood + Mucuos, Fatigue/Lethargy, Palp mass
• Tx operative, air anema and resection of death bowels and joining of healthy section

Acute Pancreatitis

Acute Pancreatitis: Patho

• Spillage of pancreatic enzymes leading too autodigestion of pancreas (lipase), more pain
• Causes:
  • Gallstones, Hyperlipidemia, infections

Acute Pancreatitis: Sx, Menifestation

• Luq pain to back eating worsens and pt will have a severe sudden pain that causes SOB
• Cullen/Turners Sign are signs of hemerage and Tetany and Fatty stools
• Causes high heart rate and leukicites levels

Acute Pancreatitis: Tx

Acute Pancreatitis- Tx supportive

Acute Pancreatitis: NPO

Acute Pancreatitis: labs and other

• increased Liver enzymes, lipse and more.
• The pt should avoid fats and acidic foods and use an NPO with electolyte monitoring

Esophigal Varies

Esophigal Varies: Patho

• Caused by an obstruction with cirrosis
• Bleeding risk, blood loss , decreased pressure and high rate

Esophigal Varies: Tx

• Pt airway should be stable pt should be stablized
• Balloon Tamponade to provide pressure and to promote cologging, reduce ammonia,

Cirrhosis

• Pathology extensive damage to cells
• Causes HCV, alchol usage,

DKA

DKA: Triad: Sx

• Hypergylcemia, ketosis, acidic breath and kussinal respiration

HHS

HHS

• decrease insulin but enough to prevent ketoacidos
• can cause seisuires, death. Give IV until it falls to 20ml

HYper gylcemia

HYper gylcemia: Patho

• ANS decrease in insulin to up sugar Sx: shakiness, Palperation and neura problems cause by to little glucose. Give 14 fast acting carbs in 15 min. If unable to 50 %glucose.