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Exam 3: renal + hematology (Iggy chapters 66, 67, 68, 40)

Terms in this set (81)

For which adverse drug effects does the nurse assess in a client who is hospitalized for an acute problem and also is prescribed an anticholinergic drug to manage incontinence? SATA.
A. Insomnia
B. Blurred vision
C. Constipation
D. Dry mouth
E. Loss of sphincter control
F. Increased sweating
G. Worsening mental function
H. Hypotension
B, C, D, G (p. 1350)
For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter?
A. 36-year-old woman who was admitted with a splenic laceration and femur fracture following a car crash
B. 48-year-old man who has paraplegia and is admitted for pneumonia
C. 61-year-old woman who is admitted following a fall at home and has new-onset dysthymia
D. 74-year-old man who had lung cancer with brain metastasis and is being transitioned to hospice for end-of-life care
D (p. 1354)
urge incontinence
the loss of urine in response to a sudden, urgent need to void; the person cannot get to a toilet in time
detrusor hyperreflexia
increased detrusor muscle contractility that occurs even though there is no sensation to void
functional incontinence
urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation
overflow incontinence
continuous leaking from the bladder either because it is full or because it does not empty completely
A client with diabetes has all of the following changes after a percutaneous nephrolithotomy procedure. Which change is MOST important to report immediately to the HCP?
A. Difficulty breathing and an O2 sat of 88% on 2L of oxygen by nasal cannula
B. A point-of-care BG of 150 and client report of thirst
C. A decreased hematocrit by 1% and hematuria
D. An oral temp of 38 C and cloudy urine drainage from the nephrostomy tube rignt after admin of an ABX
A
Which question does the nurse ask the client who has a UTI to assess the risk for pyelonephritis?
A. What drugs do you take for asthma?
B. How long have you had diabetes?
C. How much fluid do you drink daily?
D. Do you take your HTN drugs at night or in the morning?
B
When providing care to a client who had undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? SATA.
A. Urine output of 15 mL for the first hour and then diminished
B. Tenderness at the surgical site
C. Pink-tinged urine draining from the nephrostomy site
D. Hct 3% lower than pre-op value
E. Sudden onset of abdominal pain that worsens after abdominal palpation
F. BP of 180/90 that persists despite admin of pain meds
G. Presence of a few small clots with irrigation of the tube
H. Bright red drainage through the tube 12 hours after procedure
A, D, E, F, H
The client is a 62yo admitted 2 days ago with traumatic injuries and hypovolemic shock from a car crash. The nurse reviewing the client's daily lab results notices the following values. Which result is most important to report to the provider immediately?
A. Serum sodium 132 mEq/L
B. Serum potassium 6.9 mEq/L
C. BUN 24 mg/dL
D. Hct 32% and Hgb 9.2
B
Lab test most specific to renal fx
Normal range for men vs women
Important consideration for lab values
Creatinine
Male: 0.6-1.2 mg/dL, female 0.5-1.1 mg/dL
Serum creatinine doesn't decrease until at least 50% of kidney fx is lost 😬
First void guidelines for one-off specimen vs 24hr collection
One-off: must be first void
24hr: discard first void
Type of incontinence common in neuro disorders
Detrusor hyperreflexia (detrusor muscle contracts abnormally)
Type of incontinence common in enlarged prostate
Overflow incontinence (prostate enlargement causes over distension of bladder and obstruction of urethra, causing constant dribbling)
Dx tests for incontinence (7)
UA to rule out infection
C&S to identify Infectious organism
Bladder scan - post-void residuals
Post-void catheterization
CT scan - assess abnormalities
Urodynamic testing - assess fx of urinary tract
Electromyography (EMG) - assess pelvic floor muscles
incontinence mgmt (7)
Kegels
Nutrition therapy
Vaginal cone therapy
Pessary
Electrical stimulation
Magnetic resonance therapy
Bladder sling surgery
Incontinence meds (3)
Topical estrogen to perineal area
Anticholinergics - suppress involuntary bladder contractions
Oxybutynin/solifenacin/tolterodine - can cause dry mouth, dry eyes,constipation, GI discomfort
Bladder training
Appropriate for pts who are A&O & able to suppress urge to void
1) assess pt's awareness of bladder fullness
2) assess pt's 24hr voiding pattern
3) teach pt to void q45min & suppress voiding between those intervals
4) if unsuccessful, reduce interval by 15min; if successful, increase by 15min
Incontinence - habit training
Appropriate for pts who are cognitively impaired
1) assess 24hr voiding pattern & base intervals on baseline
2) cue pt to void, if needed
3) if successful, praise & reward with socialization
4) if unsuccessful, change linens/clothes and do not socialize; reduce interval by 30min
Type of UTIs (lower vs upper) more common in men vs women
Men: lower (more urethra length to alert pt to infection before it progresses to upper urinary tract)
Women: upper (less urethra = less warning before infection progresses to upper urinary tract)
Rare s/s of UTI that may signal pyelonephritis (5)
Fever
Chills
N/V
Malaise
Flank pain
UTI s/s in older adults (6)
Altered mental status
Increased confusion
Increased falls
Tachycardia/tachypnea
Hypotension
Loss of appetite!
Trimethoprim/Sulfamethoxazole: class, indication, MOA, ASE, nursing implications
Combination antibiotic/antiprotozoal used to treat UTIs (among other things)
MOA: Inhibits metabolism of folic acid by neutralized
ASE include diarrhea, crystalluria, phlebitis
Nursing implications: assess for sulfonamide allergy,
Ciprofloxacin: class, indication, MOA, ASE
Fluoroquinolone
UTIs, etc.
ASE include liver toxicity, CDAD, IICP!
Amoxicillin: class, indications, MOA, ASE, nursing implications
Aminopenicillin anti-infectives
GU infections, among others
Binds to bacterial cell wall to cause cell death
ASE include CDAD, hypersensitivity reactions, superinfection
Instruct female pts of childbearing age that drug interferes with hormonal BC
Cefdinir: class, indication, MOA, ASE
Third generation cephalosporins
UTIs, etc.
Binds to bacterial cell wall to cause cell death
ASE include CDAD, SJS, phlebitis
Fluoroquinolones: considerations (8!)
-Contraindicated in pts under 18yo & pregnancy
-Contraindicated in myasthenia gravis
-IV FORMULATION MUST BE INFUSED OVER 60 MIN!
-May increase warfarin levels
-May cause tendonitis or tendon rupture
-Monitor for prolonged QT interval in pts tasking antidysrhythmics
-May cause GI upset; give with food, except Norfloxacin
-Photosensitivity - wear sunscreen
Hyoscyamine: class, indication, MOA, toxicity s/s, nursing considerations
Anticholinergic antispasmodic
UTI r/t spastic bladder
Inhibits muscarinic effect of acetylcholine in smooth muscle of bladder
Vision changes, confusion, dizziness, syncope, fever, tachycardia, or dysuria
Causes pupil dilation and sensitivity to light
Phenazopyridine: class, indication, pt teaching
Nonopioid analgesic
UTI pain
Turns urine red/orange
Foods that can cause secondary hyperoxaluria (r/f kidney stones)
Leafy greens, cocoa, beets, wheat germ, pecans, peanuts, lime peel?! (Iggy 1362)
Type of kidney stones for which ABX are appropriate
Struvite stones - formed by bacteria splitting urea
Meds for kidney stone expulsion (4)
Thiazide diuretics
allopurinol
Calcium channel blockers
Alpha-adrenergic blockers to relax muscles to pass stones faster
lithotripsy
Urinary stones broken down by sonar, laser, or shock waves
Is blood in the urine normal after some urinary stone procedures?
Yes
Disease causing hyperuricemic urinary stones
Gout
s/s of chronic pyelonephritis
- Hypertension
- Inability to conseve sodium
- Decreased urine concentration
- Hyperkalemia and/or acidosis
KUB
kidney, ureter, bladder x-ray
Pyelonephritis treatment (4)
ABX
Pain mgmt
If pt had catheter, replace with new one
Surgical correction of structural issues that predispose to pyelonephritis
PCKD S/S (5)
HTN
Abdominal pain/fullness/increased girth
Hematuria
Constipation
Inability to concentrate urine
PCKD tx (5)
Mgmt of urinary retention
Infection control
Pain mgmt
Urinary diversion
HTN mgmt
hydronephrosis
Enlargement of one or both kidneys due to urine retention in renal pelvis
hydroureter
the distention of the ureter with urine that cannot flow because the ureter is blocked
Hydronephrosis / hydroureter tx
Mgmt of urinary retention
Infection control
Address cause of obstruction
Nephrostomy may be required
Renovascular disease
impaired renal blood flow invokes the RAAS mechanism in an effort to improve renal perfusion

May be r/t poorly controlled DM or HTN, among other things
Diabetic nephropathy
Damage to the kidneys from prolonged elevated blood glucose levels and dehydration
AKI definition
Increase in serum creatinine of >/= 0.3 mg/dl within 48 hours or >/= 50% within 7 days
OR
urine output <0.5mL/kg/hour for >6 hours
Causes of AKI: prerenal, intra renal, postrenal
Prerenal = inadequate perfusion
Intrarenal = kidney damage
Postrenal = urine flow obstruction and backup
Tetracycline renal ASE
Can exacerbate kidney impairment
Aminoglycoside renal ASE + assessment
Nephrotoxicty
Monitor peak & trough, BUN, creatinine
AKI tx (5)
Monitor renal labs, radiologic tests
Fluid challenge (500-1000 mL over 1hr)
Diuretics
Address underlying cause
Dialysis may be required
CRRT
continuous renal replacement therapy
ICU only, 1:1 staff ratio
ESRD
end-stage renal disease
GFR < 15 mL/min
Kidney fx is too poor to sustain life
sodium changes in CKD
Early: hyPOnatremia due to loss of healthy nephrons to reabsorb sodium
Late: hyPERnatremia due to decreased urine output and increased sodium retention
Why do Kussmaul respirations occur in CKD?
Reduced acid excretion = acidosis
Respiratory system attempts to compensate by blowing off CO2
Cardiac rhythm characteristic of mild hyperkalemia
Narrow, tall, pointy T-wave
Cardiac rhythm characteristic of moderate hyperkalemia
Flattened P-wave, tall T-wave
Cardiac rhythm characteristic of severe hyperkalemia
Wide and sine-like QRS that engulf the T-wave
Pre-terminal event that can turn into V-fib
CKD nursing care
Fluid restrictions
Daily wts
Monitor CMP, creatinine, BUN
Monitor ECG changes
Dietary restrictions as appropriate (electrolyte intake)
Epoetin alfa
stimulates RBC production
SC injection
Monitor Hgb, HCT, serum iron, BP
May cause HTN
Iron supplements: nursing considerations (3)
give 1 hr before or 2 hr after antacid to prevent malabsorption
N/D and constipation common at start of therapy
use straw for liquid iron to prevent staining of teeth
aluminum hydroxide: MOA, interactions, ASE, nursing considerations
Decreases serum phosphorus levels in CKD
Binds to tetracyclines, Warfarin, digoxin
Constipation, abdominal cramps
Give before meals and 2 hrs before/after other meds
Electrolytes that move out of vs into plasma during hemodialysis
Sodium and potassium move OUT
Bicarb and calcium move IN
Examples of Dialyzable Drugs (7)
Aspirin
Allopurinols
aminoglycosides
Anticonvulsants
antiviral and antifungal agents
cephalosporins
penicillins
When the nurse caring for a client with severe chronic kidney disease asks what dietary modifications he has made for the disease, he reports the following actions. Which action indicates to the nurse that additional client education is needed?
A. Using a scale to measure protein weight
B. Taking calcium and vitamin D supplements daily
C. Eliminating bananas, citrus fruits, and avocados
D. Using a salt-substitute instead of ordinary table salt
D
4 things to AVOID when a pt has an AV fistula or graft
1. Measuring BP on the affected arm
2. Venipuncture on the affected arm
3. Pt sleeping on affected arm
4. Pt lifting heavy objects with affected arm (Iggy p. 1415)
4 things to assess for in pt with AV fistula or graft
1. Thrill/bruit q4hrs while pt is awake
2. Distal pulses and circulation
3. Bleeding at needle insertion sites
4. Indications of infection at needle sites (Iggy p. 1415)
MCV : what it stands for & what it measures
Mean Corpuscular Volume
Hematocrit/RBC
Average size of RBC
Elevated: megaloblastic anemias
Decreased: iron deficiency anemia
MCHC : what it stands for & what it means
Mean Corpuscular Hemoglobin Concentration
Percent average of Hemoglobin in single RBC
Decreased: iron deficiency anemia
Type of progenitor cell that turns into RBCs and WBCs
Myeloid
Type of progenitor cell that turns into B and T cells
Lymphoid
6 hematological changes associated with aging
1. Decreased blood volume
2. Lower levels of plasma proteins
3. Fewer RBCs and WBCs (platelets don't change)
4. Lymphocytes respond less to antigens
5. WBCs elevate less in response to infection
6. Antibody responses lower & slower
Which signs and symptoms does the nurse expect to find in clients with any type of anemia? SATA.
A. Exercise intolerance
B. Fatigue
C. Glossitis
D. Jaundice
E. Leukopenia
F. Microcytic RBCS
G. Paresthesia of the hands and feet
H. Tachycardia
A, B, H
acute chest syndrome
A syndrome associated with sickle cell disease where sickled cells get trapped in the lung and cause infection
3 priority interventions for sickle cell disease
1. Oxygen
2. Fluids
3. Pain mgmt
Hydroxyurea: indication, MOA, nursing considerations (3)
- Medication for sickle cell
- Stimulates fetal Hgb production
- Antineoplastic (chemotherapy) drug excreted in all body fluids (even tears)
- TERATOGENIC; causes birth defects
- Report GI symptoms immediately- this could be a sign of toxicity
Normal serum ferritin levels
12-300 ng/mL
3 distinguishing s/s of B12 deficiency anemia
Glossitis, paresthesia, poor balance
Cyanocobalamin - definition, route, ASE, duration of tx
Vitamin B12
Can be given orally, nasally, SQ, or IM - NOT IV
No serious ASE
Lifelong tx required for pernicious anemia
Folate - definition, ASE, RDA
Vitamin B9
No known ASE
RDA 400 mcg/day (600 for pregnant pts & those who drink ETOH regularl)
Tx for which type of anemia can mask another type of anemia that then may cause irreversible neuro problems?
Tx for folic acid deficiency anemia can mask B12 deficiency anemia
Argatroban: class, MOA, indication, route, nursing considerations (3)
Thrombin inhibitor anticoagulant
Directly inhibits action of thrombin in clotting cascade
Heparin-induced thrombocytopenia
Only given IV
Monitor for bleeding; aPTT goal is 1.5-3x baseline; monitor for allergic reaction (cough, rash, dyspnea)
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