Exam 3

Question 1

Assessment with renal dysfunction

Answer 1

Labs: creatinine, BUN, CBC, Urinalysis
ask about urinary habits
hypertension, DM, and HF ???
History of UTI, kidney stones, family history

Question 2

Urinalysis

Answer 2

purpose: evaluate waste product from kidney
measures: color, clarity, –concentration, specific gravity, pH, wbc, nitrate, bacteria, rbc, ketones, glucose
-collected early in morning

Question 3

24 hour urine collection

Answer 3

purpose: measure creatinine clearance, urea nitrogen, sodium, chloride, calcium, and proteins
-discard the first void, then collect for next 24 hours
-collection restarted if any sample is discarded
-samples are refrigerated or on ice

Question 4

renal ultrasound

Answer 4

purpose: noninvasive view of internal structures, can assess size of kidney
post- remove gel

Question 5

renal CT/MRI

Answer 5

purpose: 3 dimensional imaging of organ system, can assess kidney size, cyst, or mass
prep:assess for iodine or shellfish allergy
post: assess kidney function

Question 6

Voiding Cystourethrogram

Answer 6

purpose: detects urethral or bladder injury after instillation of contrast to provide imaging of bladder and ureters.
pre: informed consent, may require anesthesia
procedure: insert catheter, instill contrast, obtain x ray, remove catheter
post: monitor for UTI first 72 hours, increase fluids, monitor output

Question 7

XRAY KUB

Answer 7

purpose: visualization of structure and detection of stones, strictures, calcium deposits, or obstructions
Pre-procedure: verify client is not pregnant, remove clothes over the area, remove all jewelry and metal objects

Question 8

Kidney biopsy

Answer 8

Purpose: removal of a sample of tissue by excision or needle aspiration for
histological examination.
* Pre-procedure: informed consent, coagulation studies, NPO for at least 4
hours, typically local anesthesia, pt must lay prone (procedure is
contraindicated if they cannot lay in this position for extended periods)
* Post-procedure: monitor for bleeding–> high risk b/c kidney is highly
vascularized–> hematuria, H&H, bruising at puncture site

Question 9

Cystoscopy/cystourethroscopy

Answer 9

Purpose: used to discover bladder wall abnormalities or occlusions of ureter or urethra
* Pre-procedure: NPO, informed consent, laxative or enema for bowel prep night before. May require anesthesia (not always)
* Intra-procedure: Lithotomy position, vitals monitoring
* Post-procedure: monitor urine output and characteristics (may be pink
tinged), irrigation may be necessary if blood clots are present, encourage
increased fluid intake

Question 10

Lithotripsy

Answer 10

Purpose: to break a stone into smaller fragments
* Pre-procedure: pt must be able to lie flat, assess for dysrhythmia (as this
procedure can cause or worsen existing)
* Intra-procedure: monitor ECG
* Post-procedure: strain urine for stone passage, bruising may occur at site
(expected finding), assist with pain management r/t stone passage

Question 11

Ureterolithotomy & nephrolithotomy

Answer 11

Percutaneous:
* Purpose: removal of stone through the skin.
* Pre-procedure: NPO, Informed consent, pt must lie prone
(contraindicated if they cannot do so for extended periods)
* Post-Procedure: monitor nephrostomy for drainage and presence of
blood
Open:
* Purpose: for large or impacted stones
* Pre-procedure: NPO, Bowel prep, Informed consent
* Post-procedure: monitor for excess bleeding, maintain fluid intake,
strain urine for passage of additional fragments, teach prevention
measures

Question 12

Care and nursing interventions for a nephrostomy tube

Answer 12

Monitory amount of drainage and type hourly within the 1st 24 hours
* A decrease in drainage amount and back pain can indicate tube obstruction
or dislodgement
Monitor for nephrostomy leaking
Sterile dressing changes
Tube flushing–> to check patency and dislodge clots

Question 13

Urinary tract infections

Answer 13

S/S: pain, fatigue, fever, confusion, frequency, urgency, dysuria, nocturia,
hematuria, retention, feeling of incomplete bladder emptying
* Diagnosis: history, physical exam, urinalysis, CBC, cystoscopy if
recurrent
* Tx: antibiotic therapy, phenazopyridine (urinary analgesic), antipyretic,
increased fluid intake, warm sitz bath 2-3 times a week can relieve pain
* Education: full abx course, drink 2-3 L/day, wipe front to back, do not
hold urine, phenazopyridine (urinary analgesic) will turn urine orange
* Labs: urinalysis–>expect positive WBCs, Nitrite, bacteria, leukocyte esterase, casts; Urine culture and sensitivity; CBC-> elevated WBCs

Question 14

Renal calculi

Answer 14

S/S: flank pain, fluctuating pain (depending on location of stone), oliguria,
anuria, dysuria, hematuria, bladder distention.
* Diagnosis: x-ray KUB, CT KUB, Ultrasound KUB
* Tx: NSAIDs, Antiemetics, Antibiotics, increase fluid intake (to aid in
passing stone and prevent further stone formation), watchful waiting (for
stones to pass), straining of urine
* Education: once stone type has been determined, patient may need to alter
intake of certain foods.
* Calcium: avoid milk and other dairy products
* Oxalate: avoid spinach, black tea, and rhubarb
* Uric Acid: decrease purine intake–> poultry, fish, gravies, red
wines, sardines
* Struvite: typically results after a bacterial infection. Avoid high
phosphate foods (dairy, red or organ meats, whole grains)
* Labs: urinalysis–> rule out infections, may be positive for RBCs,
Hyperkalemia, Hyperphosphatemia

Question 15

Polycystic Kidney Disease

Answer 15

S/S: weight gain (due to cyst formation and increased kidney size), flank pain, headache (stroke risk r/t hypertension), hematuria, hypertension (r/t decreased kidney perfusion and initiation of the RAAS system), dysuria, nocturia, constipation (enlarged kidney compresses bowels), enlarged abdominal girth (r/t enlargement of kidneys), kidney stones
* Diagnosis: ultrasound, family history/genetic testing
* Tx: blood pressure control (typically with ACEs or ARBs because they
work directly on the RAAS system), pain management (typically acetaminophen and nonpharmacologic interventions), interventions to slow progression of kidney damage (surgical cyst drainage, dialysis, smoking cessation), infection prevention, Pt will inevitably need a kidney transplant (if they live that long)
* Education: importance of diet (decrease sodium intake), importance of smoking cessation (hypertension risk),
* Labs: urinalysis: + proteinuria, + hematuria; decreased GFR; elevated BUN and creatinine levels, fluctuation in sodium level (can be wasted or retained)

Question 16

Hydronephrosis/Hydroureter

Answer 16

S/S: flank pain, anuria, abdominal asymmetry (may indicate kidney mass),
abdominal tenderness
* Diagnosis: renal ultrasonography (1st choice), UA, CBC, CT or X-Ray
KUB
* Tx: removal or treatment of obstruction–>
nephrolithotomy/ureterolithotomy, cystoscopy, stent placement;
Nephrostomy placement
* Labs: depend on severity and related kidney damage–> if left untreated
kidney damage will result in low GFR, elevated BUN, elevated Creatinine

Question 17

Pyelonephritis

Answer 17

S/S: UTI symptoms, N/V, recent cystitis or other UTI
* Diagnosis: urinalysis, culture and sensitivity, Imaging (X-ray KUB, CT)
* Tx: antibiotics, increase fluid intake, pain interventions, antipyretic,
* Education: do not hold urine, drink plenty of fluids, wipe front to back,
take full course of abx,
* Labs: BUN may be elevated (but creatinine will not), urinalysis- + WBC,
+ nitrite, + bacteria, cloudy, foul odor

Question 18

Glomerulonephritis- acute and chronic

Answer 18

Acute: results from excess immune response within the kidney tissues –> onset about 10 days after time of infection
Chronic: do not know cause
S/S: Proteinuria, hematuria, hypertension, edema (especially in the face and hands), Pulmonary edema (dyspnea, shortness of breath, crackles), neck vein distension, weight gain
Diagnosis: can only be officially diagnosed by kidney biopsy
Tx: r/t fluid overload–> diuretics, sodium restriction, water restriction; Antihypertensives, Dialysis, antibiotic therapy
Education: educate on medication, if dialysis is required–> educate on vascular access care and dialysis schedule/routine
Labs: Elevated BUN and creatinine, electrolyte imbalances r/t ineffective filtration, urinalysis: + RBC and protein, decreased GFR (normal: greater than 125 mL/min)

Question 19

Stages of bone healing

Answer 19

Hematoma formation within 24-72 hours of fracture
 Granulation tissue invades hematoma to form fibrocartilage within 3 days-
2 weeks
 Fracture site is surrounded by new vascular tissue known as a callus
within 3-6 weeks
 Callus is gradually resorbed and transformed into bone within 3-8 weeks
Consolidation and remodeling of bone can continue for up to 1 year after

Question 20

musculoskeltal assessment

Answer 20

Neurovascular assessment: Pain level/location/frequency, Sensation (presence of paresthesia), Skin temp/color, capillary refill, pulses (presence, strength, equality), movement (should have full ROM)
 Musculoskeletal assessment: Range of motion, Gait, Spinal Alignment, Muscle size and symmetry, palpation for muscle tenderness, assessment of strength and equality, Performance of ADLs
 PMH: previous traumatic injuries, previous or current illness (diabetes), family history (ex: osteoporosis)
 Lifestyle: employment, social history

Question 21

Open fracture

Answer 21

breaks through skin

Question 22

closed fracture

Answer 22

break remains in skin

Question 23

greenstick fracture

Answer 23

bends enough to snap but only cracks on one side
more common in children

Question 24

sprial fracture

Answer 24

created from twisting motion; fracture line goes around

Question 25

transverse fracture

Answer 25

complete fracture that runs horizontally across bone

Question 26

oblique fracture

Answer 26

diagnoally complete break that runs horizontally across bone

Question 27

compression fracture

Answer 27

from loading force (even gravity can cause these) ex) trauma, osteoporsis, tumors

Question 28

comminuted fracture

Answer 28

broken bone that is in multiple pieces -usually three or more

Question 29

simple fracture

Answer 29

single line fracture with no other damage

Question 30

pathologic/spontaneous fracture

Answer 30

occurs when bone structure is weakened by disease

Question 31

fatigue fracture

Answer 31

fracture caused by repeated stress over time most common in athletes

Question 32

impacted fracture

Answer 32

type of fracture that occurs when pressure is at boths sides of the bones causing it to split and broken ends jam together

Question 33

traction

Answer 33

used to maintain alignment of the bone fragments/pieces. Used to decrease muscle spasm

Question 34

skin traction/ buck's traction

Answer 34

a short-term treatment that uses weights and a pulley system to help realign broken bones in the lower limb

Question 35

skeletal traction

Answer 35

pins placed into bone

Question 36

nursing intervention traction/external fixator

Answer 36

Weights are not touching anything (I.e. bed or floor) Ropes are intact (not fraying or thinning) Pulley systems are intact Cleanliness of pins: sterile cotton swab with approved antiseptic--> clean from pin base up the pin, use different swab for each pin--> pin care should be completed at least once a shift Foot pedal is not touching the bed

Question 37

fractures

Answer 37

S/S: pain, immobility, swelling, ecchymosis (bruising), deformity, muscle spasm Dx: X-ray is preferred, MRI shows related soft tissue injury, CT used in pelvic fx  Tx: rest, immobilization, cast, reduction (closed (no surgery) or open (with surgery))  Internal fixation: hardware in the bone  External fixation: hardware in the bone and outside  Nursing Care: PMH (previous break, osteoporosis, meds, age, activity level), cause of injury, lactose intolerance/dairy allergy (potential for deficient calcium intake), hx of drug or substance abuse, neurovascular assessments, mobility assessments  Education: cast care, external fixation care, diet education (may need to increase calcium intake)  Medication: pain management, calcium supplementation  Labs: ESR (erythrocyte sedimentation rate), C-reactive protein  Both indicate presence of inflammation somewhere in the body

Question 38

Surgical procedures:

Answer 38

ORIF (open reduction internal fixation): Hardware is inside bone  External Fixation: Hardware is outside--> assess pin sites every 8- 12 hours for s/s of infection

Question 39

Amputations

Answer 39

May be Elective or traumatic  Elective: surgical removal r/t chronic disease --> more commonly the lower extremities  Traumatic: result of an injury/trauma --> more commonly the upper extremities  Nursing Care:  Physical assessment: Neurovascular assessment  Psychosocial assessment: altered body image, depressed mood, financial concerns (connect with proper resources including social worker), denial, self-esteem issues  “Assessing ability to cope, identify and acknowledge feelings, help connect with resources”  Medication: pain management, IV CALICTONIN  Post-amputation Tx:  Pain management: especially for phantom limb pain  Phantom limb pain: REAL PAIN!!!! More likely to occur if they had chronic pain in that limb prior to amputation (ex: diabetic neuropathy)  Proper stretching of area (flexion contracture prevention)  Neuroma removal (tumor of damaged nerve cells typically at the end of a limb) can reoccur after removal

Question 40

Carpal tunnel syndrome

Answer 40

Compression of the median nerve from inflammation (can occur in both hands, but more likely in the dominant hand)  Inflammation=swelling --> increased fluid in space--> fluid compresses nerve S/S: dull ache/discomfort, paresthesia that may extend up the arm, muscle weakness (may have difficulty holding small objects, turning knobs/keys, and doing other fine motor tasks)  Risk factors: repetitive stress (typing, crocheting, tennis, etc.), obesity, pregnancy, joint inflammation  Dx: Phalen’s maneuver: wrist flexion for 1 minute (numbness in hands indicates positive test), Tinel’s sign: repetitive tapping of the transverse ligament (results in paresthesia indicates positive test)  Tx: wrist immobilization and NSAIDs, behavior modification (ergonomic typing: hands parallel to each other at table, wrist support), physical therapy, corticosteroid injection, median nerve decompression surgery  Median nerve decompression surgery: post-op wrist immobilizer for 4-6 weeks, no heavy lifting

Question 41

Sprains

Answer 41

tear or stress on ligament (bone to bone)

Question 42

strain

Answer 42

tear or stress to tendon ( muscle to bone)

Question 43

RICE

Answer 43

REST ICE COMPRESS ELEVATE

Question 44

Sprains/strains

Answer 44

NSAID therapy if not contraindicated  Surgery may be needed for either depending on severity.

Question 45

Compartment syndrome

Answer 45

Rapid increase in pressure within a muscle compartment (compresses muscle, blood vessels, and nerves)  S/S: 6 P’s--> Pain (out of proportion to injury), Paresthesia, Pallor, Pulselessness, Poikilothermic (decreased temperature in one area--> r/t decreased circulation and swelling), Paralysis  Intervention: immediately notify provider, if cause is known remove it (ex: cast), emergency fasciotomy

Question 46

DVT/PE

Answer 46

S/S: unilateral pain, swelling, redness, and warmth; dyspnea; chest pain; tachypnea  Medication therapy--> anticoagulants, preventative measures (compression stockings), bed rest, O2 therapy, thrombolytics, possible surgery (embolectomy)

Question 47

Fat embolism

Answer 47

S/S: similar to DVT/PE, if in lung, a petechial rash may appear on the chest (usually the last sign to develop)  Intervention: ABC Maintenace while waiting for fat to be reabsorbed by the body. (Intubation may be required), hydration, fracture immobilization, bedrest

Question 48

Infection (osteomyelitis)

Answer 48

S/S: Fever (typically greater than 101 Fahrenheit), chills, sweats, elevated WBC, Bone pain (constant, localized, pulsating, worse with movement), swelling and tenderness Intervention: intense antimicrobial therapy via IV (for up to 3 months or until infection is eliminated), oral drug therapy may be required after IV, pain management  Complication: loss of function, persistent pain, amputation, death r/t sepsis

Question 49

Synthetic Fiberglass Cast

Answer 49

More lightweight, strong, dries quickly (within 30 minutes), can be made water-resistant

Question 50

Plaster of Paris

Answer 50

Heavy, can take up to 3 days to fully dry, cannot get wet

Question 51

5 P's

Answer 51

Pain, Pulse, Pallor, Paresthesia, Paralysis

Question 52

Nursing interventions for prevention of musculoskeletal problems associated with aging.

Answer 52

Weight bearing exercises for bone strengthening--> slows bone loss  Maintenance of adequate calcium and vitamin D intake (diet or supplementation)  Smoking cessation--> nicotine has been shown to negatively impact musculoskeletal and immune systems  Maintain regular exercise--> muscle fibers decrease in size and number with age and can atrophy if unused  Osteopenia (decreased bone density) --> safety through fall prevention is top priority  Kyphosis (hump-back) --> teach proper body mechanics

Question 53

Calcium

Answer 53

/t bone strength and muscles-->maintain adequate intake--> (9.0-10.5)

Question 54

Phosphorous

Answer 54

r/t calcium balance and bone strength--> maintain intake--> inverse relationship with Ca (Ca increases; P decreases) --> (3.0-4.5)

Question 55

Vitamin D

Answer 55

r/t calcium and phosphorous absorption--> maintain intake--> deficiency can result in calcium deficiency

Question 56

Creatinine Kinase:

Answer 56

can indicate muscle trauma--> recall rhabdomyolysis

Question 57

Estrogen

Answer 57

timulates osteoblastic activity--> deficient estrogen=weakened bones

Question 58

LDH and AST

Answer 58

can indicate skeletal muscle trauma

Question 59

CT Scan

Answer 59

verify pt does not have an allergy to contrast (iodine or shellfish allergies); assess pt’s kidney function prior to contrast as it can be nephrotoxic

Question 60

MRI

Answer 60

Remove all metal prior to the procedure, verify patient is not pregnant, verify pt does not have a pacemaker, pt must lay supine for up to 1 hour, is the pt claustrophobic