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NUr265 Exam 1
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Nur265 Advanced Medsurg Exam 1
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Galen College of NursingNur265 Advanced Medsurg
Medical Surgical Nursing: Ignatavicius, Workman, Rebar, Heimgarterner 10th edition
Exam 1 (unit 1,ch63, 53, 54, Unit 2/3 31, 32, 33,35 please see page numbers (will be on exam)
Prof Angoma
Know these Labs
Normal Urine per hr= 30mL/hr
-Creatine 0.6-1.2= Best indicator of kidney function
-BUN- 10-20 (if higher effected by stress, dehydration)
-WBC- 5-10,000
-Hemoglobin-
-Albumin-3.5-5.0
-Lipase-0-110
-Potassium- 3.5-5.0...Opposite relationship to NA.......(K=Assess heart EKG)
-Sodium- 135-145.....Opposite relationship to K ….......(Na=Assess LOC Nuero check)
-Calcium- 9-10.5
-Phosphorous- 2-4.5
MAP – 65-100 or more normal (perfusion to vital organs) = 2(Diastolic BP)+ (Systolic BP) /3
GFR- 90 or higher
Remember: Low sodium; high potassium for fluid overload; High sodium; low potassium for dehydration
AKI= Acute kidney injury- rapid loss of kidney function from renal cell damage build up of ammonia
-Onset- abrupt and reversible
-S/S- 1st sign decrease urine output, oliguria less than .5mL/kg/hr , azotomia, w/ progression = fluid overload signs; Bowels=urinary
retention; high Bp, high pulse, bounding;; crackles in lungs. (xray); infiltration; skin= edema, anascara; confusion, low sp02, increased RR;
reduced perfusion signs= MAP below 65, HR up, thready pulse, respiratory alkalosis PH low SpO2 88% ;SOB, REMEMEBR assess for
hypotension and tachycardia= SHOCK);
Assess for fluid overload- low o2 stat, edema, BP up, dyspnea, SOB, tachycardia, JVD, crackles, (Dx Xray:
infiltration); hyperventilating, resp alkalosis (Dx ABG)
-Patho- GFR decrease (filtration); can be hours or days = tell HCP if decrease in urine output (less than 30ml/hr)
-Causes- prerenal (prefusion); dehydration ,blood loss, cardiac output, heart failure, cardiogenic shock, infection, obstruction, NG suctioning,
sepsis, Vomiting/diarrhea, hypertension
intrarenal (in renal): myoglobinuria, BPH, tubular necrosis, renal ischemia, obstruction, nephrotoxicity, intrarenal infection; acute Poly
nephritis, contrast, mycins antibiotics (peak and trough), NSAIDS, naproxen,
post renal (after renal) blockage; bladder neck obstruction, bladder cancer, calculi, post renal infection, tumor
-4 phases=initiation/ onset; oliguric phase, Diuretic phase, recovery phase
1. Onset phase – decrease urine output 1-3 weeks
2. Oliguric phase= 1-3 weeks; less than 400mL/24hrs, High specific gravity; S/S anorexia, N/V, decreased urine output
3. Diuretic phase- 3-6L per day, low specific gravity; output 1000-200mL/day (have foley catheter monitor urine output)
replace fluids monitor electrolytes; may need dialysis ; Polyuria can be sign of recovery
4. recovery phase- 12month or less
Renin- angiotensin 1 and 2 = retention of sodium and retention of water
Labs- Creatine over 1.3, BUN over 20; urine less than 30mL/hr; metabolic acidosis Ph below 7.35; ABG ,high K hyperkalemia; sodium is low;
no anemia related to AKI
Nursing interventions= VS; I&O, daily weights (1 lb per day = fluid retention); labs BUN , creatine, electrolytes; acidosis (treat w/ sodium
bicarb); 2L of fluid per day; avoid/prevent HYPOtension
Assess for fluid overload- low o2 stat, edema, BP up, dyspnea, SOB, tachycardia, JVD, crackles, (Dx Xray: Infiltration);
hyperventilating, resp alkalosis (Dx ABG)
Meds- diuretics
Diet (mod protein, high carb); restrict potassium & sodium; avoid nephrotoxic meds; if poor appetite enteral or parenteral nutrition
Prevent- hydration!!!!; Na and K know levels; Avoid indwelling caths if possible; prevent infection, maintain electrolytes
Teaching- low sodium, low potassium, low phosphorous, high carb diet; only specific moderate proteins,
Complication- Pericarditis- (sac around heart) painful, pleuritic pain, friction rub, tachycardia, fever monitor for bleeding, seizures
Page 1378- physical assessment S/S- “early stages of AKI sp02- 88%” Hypoxemia (tachycardia, low BP= SHOCK) -S/S- decrease urine
output, oliguria less than .5mL/kg/hr , azotomia, w/ progression = fluid overload signs; Bowels=urinary retention; high Bp, high
1
, pulse, bounding;; crackles in lungs. (xray); infiltration; skin= edema, anascara; confusion, low sp02, increased RR; reduced perfusion
signs= MAP below 65, HR up, thready pulse, respiratory alkalosis PH low SpO2 88% ;SOB,
Page 1379 (Labatory profile table) creatine increase 1-2 every 24-48 hrs; increase 1-6 in 1 week or less; elevated potassium and
magnesium; elevated blood osmolarity
Page 1380-Interventions Nephrotoxic agents- Assess kidney function before contrast; NO /low contrast hydrate before (1mL/kg/
12hr)& after (3mLkg/1hr), Mycins antibiotic (peak and trough) avoid NSAIDS (Celecoxib, Ibuprophen, ketorolac, naproxen)
Page 1380- “monitor fluid and electrolytes in diuretic phase” Diuretic phase- 3-6L per day, low specific gravity; output 1000-
200mL/day (have foley catheter monitor urine output) replace fluids monitor electrolytes; may need dialysis ; Polyuria can be sign
of recovery
Page 1381 (Nutrional therapy) Assess food intake every shift; input equal to output + 500mL; low sodium, low potassium, low
phosphorous, high carb diet; only specific Proteins, MODERATE PROTEIN; HIGH CARB
-No dialysis protein 40g/day; Dialysis protein 1-1.5g/kg; Sodium 60-90mEq/kg; potassium restrict 60/70 mEq/kg
CKD-Chronic Kidney disease-slow progressive, irreversible loss in kidney function GFR less than or= 60mL per min for 3month or
longer
S/S= oliguria, less than 400mL/day; Anemia, metabolic acidosis ( Ph less than 7.35); azotomia ( skin breakdown), Kussmaul respirations,
potassium elevated;
Complications hypertensive crisis (headache, N/v, change in LOC) Report to Hcp; high K over 5* (Peaked t waves and st elevation
Creatine clearance test- 24hrs collect all urine, discard 1st urine
5 Stages- stage 1 (GFR 90+); stage 2 (GFR 89-60); stage 3 (GFR 59-60); stage 4 (GFR 29-15); stage 5 (GFR 15 or less) kidney transplant/
dialysis.......NORMAL GFR is 90ml/hr; stage 4 and 5 dialysis hyperkalemia
Causes- after AKI, uncontrolled DM, uncontrolled HTN, Chronic urinary obstruction, infections, renal artery occlusion, autoimmune disorders;
polycystic kidney disease
Nursing interventions= VS; I&O, daily weights (1 lb per day = fluid retention Report to HCP); labs BUN , creatine, electrolytes; acidosis
(treat w/ sodium bicarb); hear thrill feel buit
Teaching- activity rest periods, Avoid aspirin, NSAIDS, avoid spironolactone(k sparing), no antacids( mg); Avoid Mycin, Avoid Ct contrast dye,
Restrict fluid, Restrict NA, Restrict K
Diet- restrict K, Restrict NA (less than 2grams/day , low phosphorus (no dairy), low protein ( no processed meats, no canned foods); NO salt
substitutes, no leafy veggies, no carrots, no tomatoes, no avocadoes, no strawberry, organs or bananas.......BEST FOOD APPLES
Labs- *creatine – over 1.3; low h&h (anemia); NA high over145; phos high over 4.5, and low calcium; high K over 5* (Peaked t waves and st
elevation; Na high ( 135-145 ); low BUN
High K treatment= IV calcium gluconate (prevent dysthymias); Iv 50% dextrose+ reg insulin (lower K); Kayexalate
(polystyrene sulfonate); dialysis
Treatments- epoetin alfa, folic acid, iron supplement, loop diuretics (excrete Mg), Dialysis, …...hemodialysis (3-4 hrs 3x a week), peritoneal
dialysis;
Teaching- fistula; no BP on that arm, feel thrill and bruit hear; no iv infusion on that site; hold hypertensive after dialysis
Complication in hemodialysis- Disequilibrium syndrome =headache, restless, N/V confused, seizure; runs of PVC Tell HCP!!!
Table 16.3 look
-Peritoneal dialysis - ( complication: Peritonitis EMERGENCY board like abdomen, feel,rigid) the process = 1-3L of abdomen; sit in high
Fowlers position; can be done in patient home; once week; give stool softener; clear fluid ( cloudy bad = peritonitis), no machine, no partner
Page 1379- creatine increase 0.5-1mg/dL every 1-2 years; potassium up; phosphorus up; blood osmolarity up ; ABG down Metabolic
acidosis; hemocrit down
Page 1392 Table 63.8 Dietary Restrictions=
a. W/ chronic uremia= Protein=.55-1.5/kg/day; Fluid=1500mL-3000mL, Potassium= 60-70mEq daily; Sodium= 1-3g/day
phosphorous= 700mg per day
b. W/ Hemodialysis = Protein=1-1.5g/kg/day; fluid=500-700mL/day plus amt of urine; Potassium=70mEq daily; Sodium 2-
4g/day; Phosphorous= 700mg/day
c. W/ peritoneal dialysis= protein=1.2-1.5g/kg/day; fluid= restricted; potassium= no restriction; Sodium=restriction;
phosphorous=800mg/day
Page 1395- Table 63.9 Hemodialysis vs Peritoneal Dialysis
a. Hemodialysis – PROS-efficient ; treatment short time Complications = disequilibrium syndrome, muscle cramps, headache,
itchy, infection, anemia; dyrthmias, hypotension, contraindicated= severe cardiac disease; severe vascular disease; bleeding
disorders; Access= AV fistula, AV graft, CV cath; Procedure= complex; special trained person; home or dialysis center
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