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Fluid and Electrolytes, Renal, GI, Periop

pyelonephritis

inflammation of the renal parenchyma and collecting system

parenchyma

functional tissues of the organ

etiology of pyelonephritis

usually begins with colonization of lower UT, bacteria, fungi, protozia and virus

prexisting factors for pyelonephritis

vesicoureteral reflux, BPH, stricture or urinary stones

vesicoureteral reflux

a backflow of urine from the bladder into the ureter

S & S of pyelonephritis

mild fatigue, onset of chills, fever, vomiting, flank pain, bothersome symptoms of lower UTI (can subside even without treatment), pyuria (pus in urine) and bacteriuria (bacteria in urine) usually persist

diagnostic studies of pyelonephritis

urinalysis, urine C & D, ultrasound (abnormalities or stones)

pyridium

analgesic used to treat urinary tract infections and may turn urine orange

chronic pylonephritis

recurring acute pylonephritis, kidneys will appear shrunken and lose function due to scarring or fibrosis, usually progresses to end stage kidney disease if both kidneys are affected

causes of urinary incontinence

transient:confusion, depression, infection, drugs, restricted mobility, stool impaction
congenital: extrophy of the bladder (parts are outside body), epispadias (urethra is on upper tip), spina bifida

types of incontinence

stress (increased pressure), urge (few seconds warning), overflow (pressure is greater than sphincter), functional (unable to physically get there/mobility issue)

post void residual

diagnostic study, catheterization or bladder scan

incontinence

80% can be cured or significantly improved, take time, use voiding log, muscle training and prompting

urinary retention

Acute (total inability, medical emergency), chronic (not complete emptying), residual volume (what is left), more than 150 mL requires evaluation

treatment of urinary retention

acute- catheterization and treatment of cause,
chronic- schedule, alpha blockers, surgery

neurogenic bladder

dysfunction from lesion in the nervous system, types spastic (hyperactive), flaccid (overflow incontinence), complications are infection and stones, treatment is catheterization, encourage fluids and bladder retraining

urolithiasis

prescence of stones (calculi) in the urinary system

nephrolithiasis

the presence of kidney stones (calculi) in the kidney

S & S of kidney stones

deep intense pain,hematuria, pyuria, N/V, less than 1 cm are passed spontaneously, diagnosed by ultrasound, IVP (Intravenous Pyelography- exray with contrast), CT scan, blood chemistry, 24 hour urine collection,

treatment of kidney stones

Opioids and NSAIDs (anti-inflammatory properties), fluids, interventional procedures

cystoscopy

the visual examination of the urinary bladder using a cystoscope can also grab stones

lithotripsy

electromagnetically generated shock waves focused on stone to fragment stone

percutaneous nephrolithotomy

is performed by making a small incision in the back and inserting a nephroscope to crush and remove a kidney stone

patient teaching nephrolithiasis

fever, chills, flank pain, hemeturia, rine pH, fluid intake, dietary teaching, medication

urinary catheters

foley (double lumen), suprapubic (abdominal incision), straight cath (intermittent)

hypoxemia

decrease in partial pressure of oxygen in blood, mild 60-79, moderate 40-59, severe less than 40. p0rolonged or severe can lead to tissue hypoxia and anaerobic metabolism altering the acid-base balance, normal is 80-100 mm Hg

CO2

normal range is 35-45 high is acidic, low is alkalosis, ventilation is adjusted

respiratory alkalosis

caused by increased ventilations, anxiety, pain, PE

respiratory acidosis

caused by decreased ventilaitons, trauma, drowning, airway obstruction

HCO3

normal range is 22-26, low is acidosis, high is alkalosis, kedneys excrete bicarbonate ion as needed

acute symptoms indicting need for dialysis

encephalopathy (brain dysfunction), uncontrolled hyperkalemia, pericarditis, increrasing acidosis, medications or toxins

chronic need for dialysis when uremia develops

N/V, severe anorexia, increasing lethargy, confusion, fluid overload not responsive to diuretics or restrictions,

need for dialysis

GFR less than 15 mL/min

dialysis for acute pt

supportive care until kidneys heal

dialysis for chronic pt

allows them to live

dialysis limitation

does not take over kidney function of BP control, anemia (erythropoeitin), vitamin D, average life span on dialysis 5 years

hemodialysis (HD)

2-4 hours, 3 times a week, can be inpatient, outpatient or home, doc will write order for type and concetration, length of time and amount of fluid to be pulle doff

dialysate

fluid that pulls waste from blood

principlels of dialysis

urea, creatine, potassium, phosphate move from area of high concetration (blood) to area of low concetration (dialysate),
RBCs, WBCs, plasma protiens are too large to diffuse through membrane,
Na, Cl concetrations are isotonic,
glucose in the diasylate is hypertonic and pulls excess fluid from blood,
pressure gradient (hydrostatic) is created and forces extra fluid into dialysate

care of the pt on dialysis

removes lrg volumes- monitor for 1 hr HR, BP, orthostatic BP, dizziness, diaphoresis, nausea, watch for bleeding due to heparin, medications are dialyzed out, BP meds may need to be held- get directions from doc

vascular access for HD

needed for rapid and high volume blood flow

AV fistula

lasts longest and has least complication, allows for artertial flow through vein, veins become enlarged and tough, must mature for 2-3 months

AV graft

synthetic self sealing graft that connects artery and vein, used with pt with poor vessels,high rate of clotting, needs to heal for 2-3 weeks, easier for MD to put in

care of pt with AV graft or fistula

no BP or venipunctures in affected arm, palpate for thrill, auscultate for bruit, monitor circulation and aneurysm

IV catheters

for large volume high flow acute dialysis, if pt has lost AV graft or shunt, complications are infection, do not flush, heparin filled, only dialysis nurse accesses site

diabetes IV catheter site

do not access, only for diabetes nurse, heparin filled

peritoneal dialysis (PD)

peritoneum serves as the semipermeable membrane and supplies the blood, 10% of dialysis pts choose it, dialysate dwells for 4-6 hours and then is draned, 4-5 exchanges a day last one at bedtime for overnight dwell

automated PD

pt hooks up to a cycler at night, pt may need to do 1-2 exchanges during day to maintain

care of the pt on PD

need MD order for pt to do it, pt usually more expert than RN, peritonitis is major concern, assess effluent for clarity, abdominal pain, hyper BS, diarrhea, abnormal abd distension, notify MD and send specimen, monitor cath site for infection

advantages of PD

continuous process similar to kidney, no machine, slower avoid hemo unstable, more freedom with diet, can travel (no dialysis center needed), life expectancy not increased

kidney transplant

double life expectancy, live donor kidney better than cadaver kidney, after one year, cheaper than dialysis,

complications of transplant

rejection and failure (hyperacute-immediate, need to remove kidney), acute- days to months, not unusual, esp with cadaver, monitor increasing creatinine, decreased output, increased BP, chronic- months to years, usually irreversible
infections due to immunospuppression, CV disease- increased BP, lipids, cancer, corticosteroids and related symptoms

functions of the renal system

fluid and electrolyte balance, blood filtration, acid base balance, blood pressure regulation, erythropoietin production, vit D production

renal cortex

outer region that filters blood

renal medulla

middle region contains pyramids and empties into calyces

glomerulus

ball of capillaries that filters blood and retains protiens and RBCs

tubular reabsorption

water, glucose and amino acids

tubular secretion

potassium, hydrogen, and amonia are secreted from the capillaries into the urine

renal blood flow

1 liter/min, MAP- reflects hemodynamic perfusion pressure of the vital organs, over 65 adequate organ perfussion

renin

secreted by kidneys, regulates aldosterone to control BP

aldosterone

secreted by adrenal cortex and control retention of salt to control water and BP

ADH

secreted by posterior pituatary stimulating reabsorption of water in the distal tubules and collecting ducts

renal labs

BMP (BUN, creatinine, electrolytes), CBC (H&H, WBC), urinalysis (specific gravity, protien, blood), GFR

GFR

measurement of renal function, 125 ml/min

renal failure

decrease in the GFR so that the kidneys can no longer effectively filter water and waste from the blood

acute kidney injury (AKI) aka acute renal failure (ARF)

sudden onset, acute renal failure, frequently reversible with supportive care, 90% due to hypovolemia, frequently part of multi-organ failure

chronic renal failure (CRF)

gradual over months to years, progressive with loss of nephrons, symptoms occur when function is less that 20-25%,

end stage renal disease (ESRD)

condition in which kidney function is permanently lost

risk factors for renal failure

age, diabetes, severe ilness (especialy in septic and shock conditions), atherosclerotic disease, dehydration

prerenal ARF

most-common, due to conditions that affect renal blood flow, nephrons remain structurally intact, causes are hypovolemia, hypotension, sepsis, hemorrhage, renal stenosis

intrarenal ARF

direct injury to the kidneys with structural and functional damage to nephrons, ischemia, inflammation, infection, toxins, medications, IV contrast, rhabdomyolysis

rhabdomyolysis

muscle wasting disease that has been linked to statins

postrenal ARF

least common, due to obstruction of urine outflow, reversible with removal of obstruction unless it has been present long enough to cause kidney damage, causes are BPH, tumors, kidney stones, neurogenic bladder

ARF signs and symptoms

oligurina (less than 400 mL/24 hr), increased serum potassium, increased creatinine, decreased serum bicarb

ARF diagnosis

H & P, labs (BUN, ABGs, renal ultrasound, renal CT, renal agiogram,

ARF treatment

vary according to cause, rehydration, monitor fluid status for response and overload (foley, strict I/O, daily weights, orthostatic BP, assess lungs, monitor labs, treat hyperkalemia, oxygen, diuretics, dialysis

hyperkalemia treatment

kayexalate (binds with potassium for excretion in stool), IV insulin (moves K back into cells), IV glucose (to prevent hypoglycemia)

chronic renal insufficiency (CRI)

75% nephron loss,
cause- diabetes, hypertension, unsucessfully treated ARF, glomerulonephritis, autoimmune disorder, congenital defects,
early symptoms- maliase, fatigue, pruritis, headaches, weight loss, nausea, edema, hypertension, polyuria/nocturia
late symptoms- oliguria/anuria, CNS symptoms (drowsiness, confusion), numbness on hands or feet, easy bruising or bleeding, excessive thirst, breath odor of urine, uremic frost, N/V, constipation/diarrhea, stomatitis, gastritis

End stage renal disease (ESRD)

90% nephron loss

CRI complications/diagnosis

complications- decompensated heart failure, pulmonary edema, metabolic acidosis, pericarditis, pleural effusion, arrhythmias, anemia, malnutrition
diagnosis- same as acute renal failure: H & P, labs (BUN, ABGs, renal ultrasound, renal CT, renal agiogram,

CRI treatment

delay progression, prevent complications, plan for long term renal replacement, hemodialysis, peritonieal dialysis, kidney transplant

dietary and drug therapy for CRI

fluid restriction, dient restriction (low K, low Na, low protien, low phosphorus)
medications: antihypertensives, diuretics, meds to manage electrolytes, erythropoietin

pt teaching for CRI

dietary restrictions (low K, low Na, low protien, low phosphorus), fluid restriction (replace output plus 500 kL, avoid OTC meds NSAIDs, antacids and laxatives that contain Mg

PACU

post anesthesia care unit

PAT

preadmission testing, collect information regarding demographics, history consent forms, diagnositics and labs, teaching disharge planning, referrals to save time and money

elderly having special needs during surgery

comorbidities, less physiologic reserve, decreased renal and hepatic function, skin is fragile, malnutrition, decreased mobility

obese having special needs during surgery

fatty tissue especially suceptible to infection, increased risk for dihiscence, obstructive sleep apnea and need for CPAP in PACU

dihiscence

rupture separion of one or more layers of a wound

informed consent

legal mandate, surgeons responsibility to explain procedure, including benefits, alternatives, risks, complications, disfigurement, disabilities, removal of body parts, expectations

preoperative assessment (nutrtion and dentition)

nutritional and fluid status for optimal wound healing, dentition for infection control and choking on dentures or chipping compromised tooth during venting, drug hepatic and renal funtion, endocrine function (hypoglycemia from fasting before surgery, hyperglycemia from stress and will increase risk of surgical wound infection)

preoperative assessment (drug/alcohol and respiratory)

alcohol use for malnutrition and DT's (delirium tremens), CIWA scale, respiratory status, respiratory status (infection, quit smoking 4-8 weeks for optimal wound healing), teach C&DB, I/S

preoperative assessment (hepatic, renal, endocrine function)

hepatic and renal funtion (medications, anesthesia, endocrine function (hypoglycemia from fasting before surgery, hyperglycemia from stress and will increase risk of surgical wound infection)

preoperative assessment (immune, medication)

assess for allergies, ID sensitivities to meds, blood products, contrast agents, latex, food allergies and previous reactions, need to ID meds, OTC meds, herbal remedies the pt takes, corticosteriods sudden discontinuation can cause CV collapse, long term opioid use may alter response to analgesic agents, anticoagulants increase risk for bleeding

preoperative assessment (psychosical, spiritual, cultural)

anxiety, assessment of support network, readiness for teaching, assess spiritual and cultural beliefs and provide support

preoperative nursing interventions

Teaching (multiple strategies, repetitive) DB & C and I/S (prevent atelectisis and pneumonia), mobility and body movement (promotes circulation and prevents venous stasis), pain management (introduce pain rating scale, plan for analgensics, manage nutrtion and fluids (NPO after midnight), preparing the skin (special soap, hair removal-clippers)

preoperative checklist

H&P, labs, EKG, CXR, surgical consent, blood consent, medication recociliation, pt labels, pt ID, allergies, isolation, jewelry, VS, dentures, NPO status, current meds, current nursing assessment

surgical team

pt, circulating nurse (leadership role, coordinates), scrub nurse (set up, prep, count), surgeon, RN 1st asist (surgeon assistant), anethesiologist (assesses, selects and administers anesthesia, supervises condition througout the surgery)

surgical environment

surgical asepsis (absence of microorganisms, unrestricted, semi-restricted, restricted), OR ventilation exchange 15 times per hour, laminar air flow 400-500 exhanges per hour, room temp is 20-24 degrees C, humidity 30-60% less microbes in that environment

surgical classification

diagnostic (biopsy, laparotomy)
curative (appendectomy)
reparative (ORIP of hip)
cosmetic (facelift)
palliative (PEG tube)

categories of urgency

emergent- life threatening, without delay intestinal obstruction
urgent- requires prompt attention, gallbladder infection
required- needs surgery, thyroid disorder
elective- should have surgery, simple hernia
optional- decision rests on pt, cosmetic surgery

malignant hyperthermia

rare life threatening condiotion, inherited muscle disorder chemically induced by anesthetic agents, treatment is dantrolene sodium (Dantrium),
S&S: usually develop within one hour of exposure, respiratory acidosis, tachycardia >150, muscle rigidity (jaw), elevated body temp > 38.8, prognosis is poor if this condition is not aggresively treated

delirium tremens

an acute organic brain syndrome due to alcohol withdrawal that is characterized by sweating, tremor, restlessness, anxiety, mental confusion, and hallucinations, usually occurs within 72 hours

oropharynx

central portion of the pharynx between the roof of the mouth and the upper edge of the epiglottis

assessment of UGI system

history of symptoms, nutrition by mouth percentage, I&O, abilty to chew and swallow, pain, dyspepsia (indigestion), N&V, flatus (bloating), changes in appetite, bowel habits, weight gain or loss

diagnostic labs for the UGI

CBC (H&H, WBC), stool specimens, occult blood, clostridium difficile, ova and parasites

diagnostic UGI imaging studies

UGI series- oral contrast with multiple x-rays, can include swallowing and continue on to LGI tract, clear liquids and NPO after MN, push fluids after oral contrast
Chest XR or KUB (kidneys, ureter, bladder)- check placement of NGT, CXR preferred
CT/MRI

diagnostic UGI endoscopy

allows direct visualization of mucosa in esophagus, stomach and duodenum, cna do biopsies and therapeutic interventions, NPO for 8 hours prior,pt sedated, monitor for perforation, pain, and after return of gag, no PO until gag

dysphagia

difficulty swallowing, complicated by poor nutrtion, aspiration, poor dentition, oropharyngeal surgery, caused by stroke, parkinsons, alzheimers,
nursing implications- assess each time you give something PO, LOC, choking,minimize bacteria in mouth, upright position, do not rush, speech therapy consult for symptoms, hold po with altered LOC

N/V non GI causes

SE of meds, brain injuries (concussions, bleeds), brain infections (meningitis), migraines, brain tumors, vertigo, motion sickness, noxious stimuli, excess alcohol, pregnancy

N/V GI causes

obstruction, bleeding, infection or irritation

N/V assessment history

pain (OPQRST), blood coffee ground or bright red, dehydration, headache or head injury, generalized weakness, confusion, irregular HR, non-GI symptoms usually related to severe dehyration and electrolyte imbalance

N/V diagnostics

labs (H&H, WBC, electrolytes) UA- assess for dehydration, head CT, GI tests

N/V treatment

treat cause, rehydration, meds (phenergan, zophran, reglan, compazine)

Upper GI bleed

from esophagus, stmach, duodenum, causes- PUD, erosive esophagus or gastritis, gastric cancer, mucusal tears r/t forceful vomiting or injury, esophageal varices, NSAIDs, anticoagulants

UGI bleed risk factors

age > 60, severe comorbities, active bleeding, hypotension, RBC transfusion > 6 units, impatient or ICU, coagulopathy

UGIB assessment/history

hematemesis, melena, hematochezia, syncope, presyncope, dyspepsia, abdominal pain, weight loss, meds

melena

black tarry stool

dyspepsia

indigestion

hematochezia

passage of fresh, bright red blood from the rectum

UGIB physical exam

priority:assess for S/S of hemodynamic instability & shock, increased HR, decreased BP, orthostatic BP, decreased peripheral perfusion, syncope, vomiting bright red blood

UGI diagnostics

labs (CBC, H&H, platelets, troponin, APTT, PT/INR, type and crossmatch), NGT, endoscopy, CXR, CT

UGI treatment

stabilize hemodynamically, IVF (crystalloids, colloids), blood transfusions, NGT: relieves pressure in stomach, treat cause, may need to intubate if pt unable to maintain airway

GERD

backflow of contents into esophagus, incompetent sphincter, burning, can be confused with MI, symptoms greater than two weeks, diagnosed with endoscopy,

Barrett esophagus

cellular changes, squamous cells are replaced by columnar following chronic inflammation of acid reflux

GERD treatment

pt education: sit up after meals, avoid large meals, bland diet, limit caffeine, tobacco, alcohol, carbonated beverages,
meds: antacids, H2 blockers, PPI, pro-kinetic agents,
surgery: fundoplication

fundoplication

a surgical procedure for the treatment of reflux esophagitis in which the fundus of the stomach is wrapped around the lower end of the esophagus

hiatal hernia

part of stomach extrudes throug diaphram, symptoms similar to GERD, compllications are herniated portion of stomach obstruction, treatment: small meals, upright, raise HOB, fundiplication (15%)

esophageal surgery: nursing implications

do not manipulate NGT, no reinserting, or adjusting position, may damage anastomosis, call MD with any concerns re NGT

anastomosis

Surgical joining of two bowel segments to allow flow from one to another

esophageal varices

varicosed veins of esophagus, next in live for backflow if cirrhosis backs up blood
causes: portal hypertension
assessment: history, S/S liver disease, UGIB
treatment: beta blockers, endoscopic sclerotherapy, variceal ligation

PUD

gastric and duodenal ulcers, endoscopy to differentiate, S/S burning epigastric pain, non-specific GI symptoms, causes: NSAIDs, H pyori, stress, treatment: antibiotics, meds to decrease acidity, surgery for active bleed and perforation

perforated ulcer symptoms

(medical emergency) sudden onset of severe and sharp abd pain, vomiting frank blood, shock

gastric surgery

for gastric cancer and perforated ulcers, nursing managment is pain control, NGT for decompression and for feeding when BS returns, advance diet as tolerated, complications: dumping syndrome, vitamin and mineral deficiency

GI tubes purpose

decompress stomach, remove contents and keep fluid and gas from accumulating, lavage to remove toxins, diagnose GI disorder, administer meds and feedings, compress a bleeding site, aspirate contents for ananlysis

orogastric tube

(ICU only), tube inserted through the mouth into the stomach

nasogastric tube

large bore (salem sump), small bore (corpak)

what you need to know about the tube

purpose (decompression or feeding), insertion site, distal location, type of tube (salem sump, corpak, GT), amount of suction, date of insertion, initial placement confirmed by XR, bedside confirmation of placement

Large bore (salem sump)

diagnostic to evaluate gastric contents, therapeutic: lavage, decompress, prevent aspiration, provide rest for bowels, administer meds and feedings, confirm placement with XR, check placement before administering food or meds (aspirate to check for gastric contents), inserting air not accurate, I &O monitor every four hours

small bore (corpak)

replaces salem sump after ____ weeks. Only for feedings, cannot be used with suction, cannot measure residual, check placement before each feeding, notemlength at the nare, flush! clogs easily

GT/PEG & JT

end point chosen by radiology, long terms feedings, comatose patient, inserted in endoscopy lab, tract matures in 3-4 weeks, minimize movement of tube, feeding and med administration

enteral

within or by way of the intestines

parenteral

not through the intestinal tract

enteral and parenteral nutrtion

indicated if pt will be unable to eat for 7 + days, severe malnurishment or unable to meet nutrtional needs, monitor fluids balance and shifts, monitor for infections, monitor for evidence of better nutrtion

parenteral nutrition

pt is on bowel rest, cannot get sufficient nutrtion via enteral route, expensive, requires IV site, risk of infection, usually inpatient, change bag and tubing every 24 hours, excellent medium for bacteria growth, change central line dressing ever week using sterile technique

enteral nutrition

preferred when pt has funcitonal gut, maintains mucosal integrity, less complications, cheaper, easy procedure, done at home or LTC, many different formulas for pt populations (diabetic, renal,etc), needs extra hydration,

hemorrhoids

Swollen, painful rectal veins; often a result of constipation

valsalva maneuver

forceful exhalation against a closed glottis, which increases intrathoracic pressure and thus interferes with venous blood return to the heart

megacolon

an abnormal enlargement of the colon

diarrhea

acute < 14 days, chronic >2 weeks
cause- IBS, IBD, lactose, medication, tube feedings, infection, maladaptive disorder (celiac disease), aids, c-diff

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