Exam 1 Review PDF

# Study Guide EXAM 1 ## Renal * **Acute kidney Injury** * Cause: Pre / Intra / Post: Nephrotoxic Drugs * Rapid Reduction in Function * 3 Phases: Con occur in hours or days * **Causes:** * **PreRenal:** * Blood Volume * Blood Pressure * Re...

# Study Guide EXAM 1 ## Renal * **Acute kidney Injury** * Cause: Pre / Intra / Post: Nephrotoxic Drugs * Rapid Reduction in Function * 3 Phases: Con occur in hours or days * **Causes:** * **PreRenal:** * Blood Volume * Blood Pressure * Renal Artery Stenosis * Renal Vein Thrombosis * **Intrarenal:** * Anything Inside the Kidney * Glomerulonephritis * NSAIDS * Vancomycin * Gentamycin * Lupus Nephritis * Aminoglycoside * Contrast Dye * **Postrenal:** "After Kidney" * Kidney Stone * BPH * Cancer/Tumor * **Expected Clinical Manifestations:** * Oliguria: 0.5 ML/kg/hr * ↑ Creatinine and BUN * Urine Concentrate * Urine Specific Gravity 71.030 * **Complications:** * Fluid Volume Overload, Anasarca (Head to toe edema) * ↑ O2 Sat * Hyperkalemia * LOC changes * Seizures * Pitting Edema * Pulmonary Congestion * Bounding Pulse * JVD * Tachycardia * Asterixus (Hand tremor) * Metabolic Acidosis Compensation * Kussmal Respiration = Deep Rapid Breathing ## Nursing Actions: Plan Of Care * Priority: Prevent AKI * Early Recognition is key * Evaluate Client Fluid Status * Assess Daily Hydration * I & O's * Daily Weight * Characteristics Of Urine * Assess Risk Factors * Nephrotic Agents * Contrast Media * Advanced Age ## Interventions * Maintain MAP > 65 * Diuretic Therapy * Fluid Challenge (Trying to Jumpstart Kidneys) * 500-1000ML * Hemodynamic Monitoring * Nutrition: Specific Protein, Sodium and Potassium Restrictions * Kidney Replacement Tx When all other interventions have not worked ## Specific Labs and Diagnostics: * ABG's: Elevated Creatinine, ↑ K+, Phos, & Ca * Ultrasound of Kidneys: r/o Obstruction/hydronephrosis * CT OF Abdomen/Pelvis: Without Contrast * KUB * Cystoscopy or retrograde Pyelography to identify obstructions * Kidney Biopsy: (Manage BP because HTN ↑ Risk For intrarenal hemorrhage After Biopsy) ## Chronic Kidney Disease (ESRD) * Progressive * irreversible * Kidney Function ≥ 3 Months. * End Stage Occurs when Function and waste elimination unable to sustain life. ## Expected in ESRD * **Uremia:** * Metallic taste in mouth * Anorexia * N/V * Uremic Frost * Muscle Cramps * Puritis * Fatigue * Hiccups * Edema * Dyspnea * Paresthesia * **Metabolic Changes:** * Build Up OF Urea & Creatine * Na+ Retention Leads to Hypernatremia * Metabolic Acidosis - HYPERkalemia * Cat, Phosphorus, Vitamin D Concerns ## Complications * **Cardiorenal Syndrome:** * ECG Changes: HF, S3 * JVD * Crackles, Pulmonary Edema, Tachycardia, hyperpnea * Pericarditis * **Other System Significant Changes (Core With ESKD):** * **Hematologic:** * Anemia, Low Iron & Folic Acid & Immunity * Teach Client about ↑ Risk Of Infection * **GI:** * Uremic Fetor, Stomatitis, PD PUD * **Neurological:** * Ataxia, Peripheral Neuropathy * Tremors, Seizure, Coma * **Musculoskeletal:** * Bone Pain, Muscle Weakness, Pathological Fracture ## Priority Nursing Interventions * Manage Fluid Volume * Assess for development of FVO ≥ 4hrs * Dependent Edema * Rapid Shallow Breathing. * Wheezes * Rapid, Bounding Pulse * JVD * Auscultation of Crackles/Wheezes * Fluid Restrictions * Strict I & O's With Daily Weights * Improve Cardiac Function * Manage HTN: * Thiazides, *CCB's, ACEIs, alpha - Adrenergic, Beta-Adrenergic blockers, and vasodilaters * Ongoing Assessment For S&S OF HF, dysrhythmias & Reduced Cardiac Output * Don't give CCB history Of HF exists ## Dietary Teaching * Sodium, Protein Restrictions * Allowed Amounts Change depending on Client Status * Restricted Diets: High Calorie Supplements needed * K+ Restrictions * Phosphorus Restriction: Take Phosphorus Binders * Give Calcium & Vitamins B and D * Avoid Antacids Containing Mg ## Hemodialysis * Removes excess Fluids and wastes * Restores Chemical & Electrolyte Balance ## Nursing Considerations * Coordinate with HCP regarding Meds to be held/Given * Get Wet to dry weight * Pre Vs, Assess Access * Common Past Dialysis Problems * Assess for Hemorrhage * Avoid invasive Procedures 4-6hr Following Dialysis ## Complications OF Hemodialysis * Hypotension, HA, Nausea, Dizziness & Muscle Cramps * Disequallibrium Syndrome: (Pulled OFF too Much Too Fast) * Restlessness & Headache * Cordiac Events * Cordiac Arrest, Pericordial Disease * Concern IF PVCs Occur = HYPERkalemia ## Nursing Core OF AV Fistula or Graft * Aseptic technique When managing * BP - NO BP, No Sticks * ROM * Huge Risk FOR Infection * Monitor For infection * Palpate and Ausculate * Feel for Thrill & Bruit * No heavy lifting Or Carrying Or direct pressure * Tight Bondages ## Peritoneal Dialysis * Repeated Cycles of instilling Fluid into the Peritoneal Cavity in abdomen * Allowed to dwell for Period Of time then drained * Can be Ambulatory * Much slower than hemodialysis * Rubber Catheter into Abdominal Cavity for infusion of dialysate ## Nursing Care For Peritoneal Dialysis * Before Tx: Evaluate Baseline VS, LHeight, Labratory Tests * Masks Aseptic Technique * Continually Monitor For Respiratory Distress, Pain, discomfort. * Assess VS q 15-30min. * Monitor Prescribed dwell time, initiate OutFlow * Maintain Accurate inflow & Outflow Records * Monitor Changes in Color Of Outflow * Moniter for Signs Of infection ## Complications OF Peritoneal Dialysis * Peritonitis: Cloudy Dialysate, Abdominal Pain, Rigid board-like Abdomen, Fever * Exit Site/Tunnel Inections: * Pain * Bleeding at Site * Poor dialysate Flow: * Dialysate Leakage * Bowel Perforation ## GI * Acute Pancreatitis: * Pain is described as an intense Boning: (Feeling going through the body) and Continuous and worsened by lying in Supire Position * Severe, Constant Pain in Mid Epigastric - Lua To Flank * Relief in Fetal Position * N/V * Signs/Symptoms ## Diagnostics * CT is Most Sensitive Diagnostic: * Expected ↑ WBC and Sed Rate * ↑ Amylase - Lipase, Tripsin, ↑ Blood Glucose ## Complications (This should not be happening) * Vital Signs: Increased Prersistent Elevated Temp * Tachycardia & Hypotension - Shock * Paralytic ileus * Pneumonia, Pleural Effusions, Atelectasis & Dyspnea * ARDS * Necrotizing Hemorrhagic Pancreatitis: Dead & Bleeding * Grey/Blue discoloration to Periumbilical & Flonk Area (Cullerme, mers sign) * Intraabdominal hemorrhage * Sudden in Ca & Mag Levels ## Priority Nursing Interventions * 1st priority: Airway - Breathing - Circulation* * Vital Signs & Respiratory Status * ABD Pain * Monitor I & O's * NPO, 0.9% NS IVF * Pain Management: Morphine or Hydromorphine - PCA * Side Lying Position * NGT For Gastric Decompression: Meds: Famotidine & Pantoprazole ## Diet Changes * No Spicy or Caffeine * Bland Food * High Calorie Meals: High Carb, high Protein ## Chronic Pancreatitis * Long term Inflammation * Remissions & Exacerbations * #1 Cause = Alcoholism ## Other Causes/Symptoms * Chronic Obstructive CBD, Autoimmune, Idopathic * Pain: Continuous burning or gnawing dullness with Periods Of Acute exacerbations (Flare Ups) - Intense & Relentless. * Muscle Wasting * Jaundice * S/S OF Diabetes * Dork Urine and Steatorrhea Stools * Ascites * Fatigue * N/V ## Nursing Interventions * Pain Control: * NPO * Opioids * H2 Blockers & PPIs (Due to Malabsorption) * TPN or PPN ## Home Care Management * Nutritional Needs: * Eat blond, Low Fat & high Protein & Moderate Corb Meals * Small Frequent Mea Is * High Calories * Pancrelipse & Creon: Pancreatic Replacement Therapy * Teaching Needs * Monitor For Skin breakdown. * Monitor Consistency Of Stools. * Take Pancreatic Enzymes with food. ## Cirrohsis * Extensive & irreversible Scaring Of the liver * Results of hepatic inflammation & Necrosis * Developes Slowly * ETOH - Acpatitis * Biliary Obstruction - Drugs and chemica's * Fatal Without transplant ## Expected Clinical Cirrhosis Symptoms * **Early Stage** * Fatigue, Weight loss, Enlarged Liver * Anorexia, N/V, ABD Pain * **End Stage:** * Ascites, Brusing, Jaundice * Clothing Disorders, Ammonia Levels. * Petechia, Palmor Erythemia. * Gynucomastia & Impotence. * Jaundice, Icterus (Yellowing Of eyes) * Spider Angiomas, Dry Skin ## Diagnostics * Labs: TALT, AST, Bilirubin * Decreased Albumin * Thrombocytopenia (Low Platelets) * Prolonged PT/INR * Physical Assessment, MRI/CT, EGD ## Complications (Anything having to do w/ bleeding) * **#1 Cirrhos is** * **#2 Portal hypertension (Gets Backd up):** * Esophageal Varicies * Ascites: Shunting Cell Function * Encephalopathy * Hepatopulmonary * Bacterial Peritonitis * **Ascites** * Hepatorenal Syndrome * Comfort Measures * **Low NA Diet, FSE Monitor, Vitamins, Diuretics, Paracentesis** * **Prevent Respiratory Complications** * **Use BR Prior to Paracentesis** * **Obtain Pre & Post Weigh** ## Hepatoencopolopathy * **Stage 1:** Impaired thinking, Slumed, Slow Speech * **Stage 2:** Mental Confusion, Asterixis * **Stage 3:** Morked Confusion Progressively deteriorating, Muscle Twitching. * **Stage 4:** Coma, Fector Hepaticus ## Patient Education * **Lactulose**: Removes excess Amants of Ammonia * **Contact HCP:** Muscle Weakness, irregular Heartbeat, light heatedness. * **Nursing Interventions:** * Manage Fluid Volume: Nutrition F&E Balonce * Bleeding Precautions. * Medication Therapy: PPI/H2 Blockers, Broad Spectrum Antibiotics * Big Risk for developing Ulcers. * Avoid: Acetaminophen, NSAIDS, ETOH & Illicit Drugs * OTC Meds Herbs * Small Frequent Meals: High Calore, High Corb, Moderate Fat * Protein ## Cardiovascular * **Angina:** * Chest Pain due to ischemic Heart Disease: * Stable Angina: Occurs with exercise, relieved by Rest or Nitroglycerin * Frequency, duration, and intensity Of Symptoms remain the Same Over Several Months. * Unstable Angina: Chest pain or discomfort that occurs at rest or with exertion and Causes Severe Activity limitation * May Present with ST changes On a 12 lead ECG but do Not have changes in troponin Levels. ## Diagnostics * EKG, Stress test, CT/MRI, Echocardiogrom, Coronary Angiogram, Cardiac Catheterization, Chest X-Ray ## Meds * Nitroglycerin, Antihypertensives: (beta blockers, Calcium Channel Blockers, Statins, Anticoagulants ## Treatment * Stop All activity, Sit or rest in beds * Administer Meds As ordered * Administer Oxygen. * Assess the Patient White Performing Other Necessory interventions ## Complications * **Heart Attack (MI):** * HF * SOB * Stroke * **Angina VS MI:** * Chest Pain Unrelieved by rest or Nitroglycenn, Lasting > 30 min is indicative OF MI * MI's Can also have Other Symptoms such as Shortness of breath, N/V, Diaphoresis ## MYO Cordial Infarction * **PT Presentation - S/S - Clinical Manifestation:** * Pain to Jaw, Back Shoulder or Abdomen - Substernal Chest pain: 730min * Doesn't Go Away With Nitro* * Occurring Without Cause * Diaphoresis * Palpitations * Dyspnea * SOB * Anxiety and Fear * Dizziness & Fatigue * N/v * Epigastric distress * Acute Confusion * ECG within 10 mint ## Nursing Interventions and Monitoring * **#1 Assess BIP and HR:** * Cordiac Rhythm * Sinus Tach w/pvcs * Peripheral Pulses and Skin - Sweaty Skin? * **Assess For HF:** * Heart Sounds (53: Ventricular Compromise * Lung Sounds: JVD * **Need 12 Lead ECG:** * Cardiac Enzymes: Troponins TI (Rise quickly) * Creatine kinase - MB (CK-MB) * **Manage Pain and ↑ Tissue perfusion:** * A-B-C * Continuous ECG Monitoring. * IV Access * 12 Lead ECG within 10 min * ASA - Clopidogrel * Nitroglycerin (vasodilation) - Check Bp Frequently * Morphine Sulfate * O2 for hypoxemia * B-Blockers, ACEIS & ARBs. ## Reperfusion Theropr Must occur ## Complication: Death and/or Development OF HF * #Arr Sign Of HF Requires immediate Follow up ## Complications * **Heart Failure:** * **Left sided HF:** Pulmonary Congestion * KEY s/s: Dyspnea, Crackles, Fatigue * Pink /Frothy Sputum * Left = Lungs * **Right Sided HF:** Systemic Congestion * KEY s/s: Peripheral Edema, Ascites * Jugular vein distention, hepatomegaly *Right = Rest OF Body * **TX: Diuretics, Digoxin** ## Procedures * **Thrombolytic Therapy:** * Dissolves thrombi in the Coronary Arteries & Restores Blood Flow to the Mrocardium * Start infusion within 30 Mins OF ED Admission. * **Contraindications:** Recent Abdominal Surgery, invasive Procedure, Stroke. * Fibrinolytics: Tissue plasminogen (t-PA) * Altepase * Tenecteplase (TNKase) * Reteplase * **Who Cannot Receive Theropy?** * HX OF intracranial hemorrhage * Suspected Aortic dissection * Recent head trauma * NSTEMI * Active Bleeding. * **Post - Treatment:** * Monitor For Change OF LOC * Moniter Clotting Studies. * Spontaneous Bleeding: * Monitor For Intermal bleeding. * Heparin/Enoxaporin: * No Chonge Chest Pan or ST Segment ## PCI - Percutaneous Coronary Intervention * Reopens Clotted Artery & Restore Perfusion * 2-3 hr OF Onset OF ACS * 90 Min For STEMI * **POST PCI:** * Telemetry & vitals * HOB Less than 30° (4-4) * Keep Leg Straght * Pulse Checks OF Affected extremity * IVF * Assess site For Bleeding * Will gom go on dual Antiplatelet TX: * Beta Blocker * ACE or ARB * Nitrate ## Post PCI Cath- Complications * Fatigue: W/SOB * Urine output OF ≤30mL/hr * Cool Clammy extremities * Or Absent peripheral pulses * LOC changes * Crackels in Lungs up to Mid level. ## Coronary Artery Bypass Graft (CABG) * **Post OP-Nursing Considerations:** * Hemodynamic Monitoring. * Mediastinal & pleural chest Tubes. * Epicardial Pacer wires to Pacemaker: * Sterile technique during all dsg Changes * NotiFV Provider For chest tube drainage > 150 mu/hr * **Post CABG Complications:** * Watch For dysrhythmias. * HTN * Hypothermia * F&E Imbalances * Angina Pain * Chorge in Loc. * Bleeding * **Cardiac Tamponade:** * Mediastinal tube ## Pericarditis * **P+ Presentation - Signs and Symptans:** * Substernal Pain radiating to Side Of Neck, Shoulder, Back * Aggravated by breathing, Coughing, Swallowing * Pain increases When Supine, Relieved by Sitting upward, Leaning Forward * Pericardial Friction Rub * Afib is Common * ST - T Wave Spikes ## Interventions * NSAID's → Corticosteroids May be used * Pericardie ctomy * Antibiotics * Monita For Worsening SX. * Position For Comfort * Pericardial, EFFusions = Tamponade * Think Fluid ## Lab Values / Diagnostics * ↑WBC, EKG Showing StorT * Spirng * Echocardiogram ## Cardiac Tamponade * Compression OF the heart due to the Accumulation of Fluid in the Pericordial Sac * PT Presentation - S/S * JVD - But Clear Lung Sounds. * Hypotension: * Distant - MUFFled heart sounds * Paradoxical pulse: Everytime Pt inhales Systolic Drops * Exhale Systolic goes up. ## Diagnosis * Chest X-Ray, Echocardiogram ## Treatment: * Pericardiocentesis (Removal Of Fluid for Pericordial Sac) ## Endocarditis * PT Presentation - Signs & Symptoms * Infection of the endocardium: Linner layer of the heart) * Bacterial Endocrditis * Vegitation growth On heart: Con break OFF and embolize anywhere in Bady ## Expected S/S * Fever W/Chills, Night Sweats, Malase * Anorexia & Weight Loss * Cordiac murmur (Regurgitation like) * Petechiae * Splinter hemorrhages. * Oslers Nodes/Jonewar lesions ## Complication * HF - Arterial embolization * Pulmenory - Silken (Rebound tenderness) * Kidney - Flank Pain * Hematuria * Pyuria * GI tract * Sudden Abdominal Pain & Distention * Brain - Neurochanges ## Endocarditis - Interventions * Antimicrobials IV: * PCN or Cephalosporins * 4-6 Weeks * Anticoagulants Avoided * Valve Replacement * Education: * Good oral hygiene. * Aseptic technique: Clean open Areas & Apply Antibiotic Ointment. * Monitor & Record Daily Temps * Report Signs of recurring Endocarditis & HF * Lab Values / Diagnostics: Positive Blood Culture * Echocardiogran ## Dilated Cordiomyopathy * Happens after extensive USC OF heart due to High BP * Il Like an old Rubber Band" Looses Elasticity ## Interventions * Goal: ↑ Cardiac Output * S/S: SOB, Fatigue, dizziness, Edema, Arrythmias, Murmurs. * Meds: Diuretics, Vasodilators, Cardiac Glycosides, Beta Blockers * Teach PT to report Palpitations, Dizziness, Syncope * May need Antidysrhythmic (Dig) * AICD- Something to control Sx * Teach Pt to look out For Signs OF HF. * Once it gets Very Bad - Pt will need heart transplant. * Diagnostics: Echocardiogram, Coronary Angiogram, EKG ## Abdominal Aortic Aneurysm * Asymptomatic When First discovered by routine examinatia or Juring an imaging Study Performed For another Reason. ## What to Assess For? * Abdominal, Flonk, or back Pain * Described as Steady with Inoving quality, Unaffected by movement, and lasting For hours or days. * Pulsation in the upper Abdomen Stightly to the left of the midline between the xiphoid Process and the Umbilicus mar be present * A detectable Aneurysum is at least 5cm in diameter * Auscultate For a bruit over the mass, but Avoid Palpating the mass: Risk For Rupture!! * S/S OF HYPovolemic Shock: * Hypotension, diaphoresis, Loc, Oligurnia, Loss OF Pulses distal to rupture, and dysrhythmias * Retroperitoneal hemorrhage - Hematomas in the Flanks (Lower Back) * Rupture into the Abdominal Cavity Causes Abdominal distention ## Nursing interventions / Monitoring. * VS, ABGS, Cordiac Rhythm, Urine Cutput: * PX: CT, Ultrasand * 4cm & Below = Concervative Theropy * 5cm Will need Surgery ## Thoracic Aortic Anneurysm * Assess For Back Pain. * S/S: SOB, hoarseness, and difficulty swallowing * Mass Maybe visible Above Suprastemal Notch * Assess For Sudden and excruciating back or Chest Pain ## Surgical Management * For Patients with a rupturing Abdominal Aortic Aneurysm Or a thoracic aortic Aneurysm, emergency Surgery is performed. * Stents (wirelike devices) are inserted Percutaneously through Skin), Avoiding Abdominal incisions. ## Complications Of Stent Repair * Conversion to Open Surgical Repair * Bleeding * Aneurysm Rupture * Peripheral Embolization - Misplacement Of the Stint Graft: * Endoleak * Infection * No heavr lifting Obwects (More than 15-20lb) For 6-12Wk after Surgery * Caution with Activites that involve Pulling, Pushing, or Straining ## Aortic Dissection * Caused by a sudden tear in the aortic intimia, allowing blood to enter the aortic Wall * Highly leathal and represents an emergency situation * Pain: Shorp, Tearing, Ripping, and Stabbing * Pain on Anterior Chest, back, Neck, throat, Jaw or teeth * S/S: Diaphoresis, N/V, Faintness, Pallor / ash grar Skin, Rapid and Weak Pulse, and apprehension. * Pt becomes Rapidly Hypotensive. * Neurological deficits: Altered Loc, Parapesis, and Strokes con Occur ## DX: * CTA & TEE @ Bedside ## INTERVENTIONS * 2 Lorge bore Iv to infuse 0.9% Sodium Chloride * indwelling urinary Catheter * Iv Betablocker to to Lower HR and BP: * if ineffective, Nitropruside Or Nicordipine hydrochlorite May be used ## Long term Medical Tx * Recommended target For BP: Less than 120/80 * Calcium Channel antagonists: LAmlodipite) ## EKG Strips * **Sinus Bradycardia:** * Can be Caused by Metropolol * HR Leo * **Causes:** Cardiovascular disease / Infection, Hypoxia, Meds * **Tx:** Atropine Or Pacemaker For Sympathetic Bradycardia. * **Sinus Tachycardia:** >100Bpm. * **Causes:** Physical Activity, Anxiety Pain, Anemia, Compensation for Cardiac autort * **Meds:** Albuterol & Stimulants. * **Atrial Fibrillation:** * High Risk For Clots * **Tx:** Cardioversion, Antiarrhythmics, Anticoagulants * **Ventricular Tachycardia:** Usually due to Ischemia / Heart Disease * Tx: with pulse treated with Synchronized Cardioversion. * VTach W/O Pulse = Defibrillation * **VTach Prepare For Cardioversion** * **Ventricular Fibrillation** * Defib Afib * Rapid ineffective Quivering OF heart ## Mitral/Atrial Stenosis * **Mitral Stenosis:** * Fatigue * Dyspnea on exertion * Paroxysmal Nocturnal Dyspnea * Hemoptysis * Hepatomegaly * Neck vein distention * Pitting Edema * A Fib * Rumbling, Apical diastolic murmur * **Atrial Stenosis:** * Dyspnea on exertion * Angina * Syncope on exertion * Fatigue * Orthoprica * Paroxysmal Nocturnal Dyspnea. * Harsh, Systolic Crescendo decrescendo Murmur ## Pt Presentation - Signs/Symploms * Dyspnea On exertion, Orthopnea, Fatigue, Pink Frothy Sputum, Acites ## Treatment: * Diuretics, Beta-Blockers, Anticoagulants, Antibiotic Prophylaxis * Valve Replacements: * Biological Graft also known as Zenograft * Bio Grafts are used more often in Older patients * Do not need lifelong Anticoagulation. * Mechanical valves: * Used in Younger Patients, Last about 20 Years. * Require life time long Anticoagulation. * Loud Clicking Noise. * Freqvent Lab testing