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NUR 265 ADVANCED MED SURG > UNIT 1 Chapter 63 Acute Kidney Injury and Chronic Kidney Injury > Flashcards

UNIT 1 Chapter 63 Acute Kidney Injury and Chronic Kidney Injury Flashcards

1
Q

Lab value for Creatinine

A

Male: 0.6-1.2 mg/dL
Female: 0.5-1.1 mg/dL

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2
Q

Lab value for Blood Urea Nitrogen

A

Both Sexes: 10-20 mg/dL

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3
Q

Lab value for GFR

A

90-120 mL/min

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4
Q

Lab value for Platelet count

A

150,000-400,000 mm3

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5
Q

Lab value for PT

A

Both Sexes: 11-12.5 sec
Pregnant: decreased
** 1.5-2.5 times the normal
control (on warfarin)

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6
Q

Lab value for INR

A

Normal is 0.9-1.2 seconds
Desirable therapeutic level is 2-3
times the normal (on warfarin)

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7
Q

Lab value for aPTT

A

Both Sexes: 30-40 sec
** 1.5-2.5 times the normal
control (on Heparin)

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8
Q

Lab value for HCT AND HGB

A

HGB-Male: 14-18 g/dL
Female: 12-16 g/dL

HCT-Male: 42-52%
Female: 37-47%

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9
Q

Lab value for Na

A

Both Sexes: 135-145 mEq/L

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10
Q

Lab value for K+

A

3.5-5

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11
Q

Lab for WBC

A

5,000-10,000

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12
Q

What is Acute Kidney Injury?

A

sudden dysfunction to the kidney that is reversible.
-The causes of AKI are reduced perfusion to the kidneys, damage to kidney tissue, and obstruction of urine outflow.

Sudden (hours to days)

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13
Q

What are the s/s of AKI

A

OLIGURIA
-azotemia;build up of nitrogen waste
-fluid overload
-Anemia
-pulmonary crackles,
-dependent and generalized edema (anasarca),
-decreased oxygenation
- (low peripheral oxygenation or SpO 2), -confusion,
-increased respiratory rate,
-dyspnea
-tachycardia
-bounding pulse
-hypertension

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14
Q

What are the 3 causes of AKI?

A

-Pre-Renal AKI
-Intra-Renal AKI
-Post-renal AKI

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15
Q

What is the cause of Pre-Renal AKI

A

Prerenal AKI is caused by a source outside of the kidney creating conditions that impair renal perfusion. Common causes include
-Shock,
-Dehydration,
-Hypovolemia
-Fluid volume Deficit
-Hemrohage
-Burns, and
-Sepsis.

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16
Q

The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient’s recent history?
a. Pyelonephritis
b. Dehydration
c. Bladder cancer
d. Kidney stones

A

b. Dehydration

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17
Q

A marathon runner comes into the clinic and states <I have not urinated very much in the last few days.= The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate?
a. Give the client a bottle of water immediately.
b. Start an intravenous line for fluids.
c. Teach the patient to drink 2 to 3 L of water daily.
d. Perform an electrocardiogram.

A

a. Give the client a bottle of water immediately.

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18
Q

What is the cause of Intra Renal AKI

A

Intrinsic renal injury occurs inside the kidney by disorders that directly affect the renal cortex or medulla. Examples of disorders causing intrinsic renal AKI include allergic disorders, embolism or thrombosis of the renal vessels, and nephrotoxic agents. P

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19
Q

The nurse is assessing a client with a diagnosis of intrarenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient’s recent history?
a. Pyelonephritis
b. Dehydration
c. sepsis
d. Kidney stones

A

a. Pyelonephritis

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20
Q

What is the cause of Post Renal AKI

A

Postrenal AKI is caused by a urine flow obstruction. The obstruction can be caused by tumors, kidney stones, or strictures

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21
Q

The nurse is assessing a client with a diagnosis of postrenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient’s recent history?
a. Pyelonephritis
b. Dehydration
c. sepsis
d. Kidney stones

A

d. Kidney stones

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22
Q

Which of the following Labs would you suspect to be increased for a patient with Akute Kidney Injury? SELECT ALL THAT APPLY

Creatinine
Potassium
Sodium
BUN
GFR
pH(Acidosis or alkaline)
Calcium
Magnesium

A

Creatinine
Potassium
BUN

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23
Q

Which of the following labs would you suspect to be decreased? SELECT ALL THAT APPLY

Creatinine
Potassium
Sodium
BUN
GFR
pH
Calcium
Magnesium

A

Sodium
GFR
Ph(Acidosis)
Magnesium
Calcium

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24
Q

Your patient with Acute Kidney injury had been diagnosed with pre-renal AKI secondary to dehydration. Which of the following statements by the patient required intervention?

A. my recovery can take up to 1 day.
B.This diagnosis occurred suddenly due to dehydration.
C. Oral rehydration may be in my care plan.
D. If my dehydration gets worse I may need dialysis.

A

A. my recovery can take up to 1 day.

FROM BOOK
- Resolution of kidney injury may occur over several months, and follow-up care may be provided by a nephrologist or by the primary health care provider in consultation with the nephrologist. Frequent medical visits are necessary, as are scheduled laboratory blood and urine tests to monitor kidney function. A registered dietitian nutritionist can plan modifications to the patient’s diet according to the degree of kidney function and ongoing nutrition needs. Fluid restrictions and daily weights may be advised to avoid fluid overload while kidneys are recovering.

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25
Q

Phases of Acute Kidney Injury

A

Onset Phase:
* Starts with the precipitating event and continues until oliguric development.

  • Oliguric Phase:
  • Lasts 1-3 weeks.
  • The longer this phase lasts, the poorer the prognosis.
  • Dialysis may be required during this phase.

*Diuretic Phase:
* Urine output may be 1000 – 2000 ml/day.

  • Recovery Phase:
  • 3–12 months.
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26
Q

Oliguric Phase, how long does this phase last?

A.1-3 weeks
B. 6 hours
C. 5 hours
D. 2 hours

A

** Lasts 1-3 weeks**
* The longer this phase lasts, the poorer the prognosis.
* Dialysis may be required during this phase.

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27
Q

What occurs during the diuretic phase?
What is the priory nursing action in the phase?

A

*Diuretic Phase:
* Urine output may be 1000 – 2000 ml/day

increase fluid intake to prevent dehydration.

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28
Q

How long does the recovery phase last?

A
  • 3–12 month
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29
Q

Medical management priority for patients with Acute Kidney injury?
What is the Nursing Care plan?

A

Prevent acute renal failure.
* Adequate hydration and diuresis in high-risk patients.

  • Maintain fluid and electrolyte balance.
  • Monitor serum and urine electrolytes. *

Replace renal function.
Patient may need dialysis.

Prevent infection

Prevent infection
* Significant cause of death in patients with ARF.
* Avoid indwelling catheters if possible.

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30
Q

What is the most common diuretic that is used for patients with Acute Kidney injury in the Oliguric phase?

A. Spironlactone
B. Furosemide
C. Eplerenone
D. Triamterene

A

B. Furosemide

-potassium wasting diuretics aid in creating fluid and electroytes balance or help recover from fluid and electrolyte imbalance

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31
Q

You are precepting a new graduate nurse in the ICU. She is currently assigned to a patient with Acute Kidney Injury. She is about to call the HCP to order a urinary catheter due to the patient’s oliguria. What is your priority action?

A. Teach her the best way of initiating an order for her patient
B. tell her to reduce the iv hydration for her patient.
C. immediately stop her from asking for that order because the urinary catheter may lead to infection which is the major cause of death in these patients.
D. Ask her to order an diuretic instead.

A

C. immediately stop her from asking for that order because the urinary catheter may lead to infection which is the major cause of death in these patients.

Prevent infection
* Significant cause of death in patients with ARF.
* Avoid indwelling catheters if possible.

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32
Q

What’s a complication that would warrant immediate attention for a patient with Akute Kidney Injury?SELECT ALL THAT APPLY

A. seizures
B.hypertenstion
C.Oliguria
D.urine specific gravity 1.005
E. WBC 20,000

A

A. seizures
E. WBC 20,000

due to hypocalcemia, and fluid imbalance can cause seizures

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33
Q

A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944 mcmol/L) and a blood urea nitrogen (BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client’s history?
a. <Have you been taking any aspirin, ibuprofen, or naproxen recently?
b. <Do you have anyone in your family with renal failure?
c. <Have you had a diet that is low in protein recently?
d. <Has a relative had a kidney transplant lately?

A

a. <Have you been taking any aspirin, ibuprofen, or naproxen recently?

There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory
drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the
patient since both the serum creatinine and BUN are elevated, indicating some renal problems.
A diet high in protein could be a factor in an increased BUN.

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34
Q

Which of the following drugs are contraindicated for patients with Acute Kidney Injury? SELECT ALL THAT APPLY

A. Insulin
B. Metformin
C. Acetominophin
D. Contrast Iodine
E. Gentamycin
F. Furosemide
G. Spironolactone
H. Aspirin,
J. Ibuprofen
K. Naproxen

A

B. Metformin
D. Contrast Iodine
E. Gentamycin
G. Spironolactone
H. Aspirin,
J. Ibuprofen
K. Naproxen

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35
Q

A client with diabetes mellitus type 2 has been well controlled with metformin. The client is
scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the
nurse take at this time?
a. Teach the client about the purpose of the MRI.
b. Assess the client9s blood urea nitrogen and creatinine.
c. Tell the client to withhold metformin for 24 hours before the MRI.
d. Ask the client if he or she is taking antibiotics.

A

c. Tell the client to withhold metformin for 24 hours before the MRI.

Contrast media can be nephrotoxic (damaging to the kidneys). Metformin can also be nephrotoxic and the client should not be exposed to two agents. Clients who have diabetes are already at risk for renal damage.

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36
Q

Your patient is in the oliguric phase and is currently in Fluid volume overoad.What can edema cause?
A. high perfusion
B. decreased skin integrity
C. 30 grade of pitting edema
D. hypotension

A

B. decreased skin integrity

When your patient is the fluid overload state monitor for skin integrity

The skin is most likey to tear when a patient has edema. Which can lead to infection , which is the major cause of death in Acute Renal Failure patients.

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37
Q

What are risk factors medications or types of food for an increase state of Acute Renal failure?

A

Avoid risk factors
* Contrast media
* Nephrotoxic medications
* Foods such as certain proteins

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38
Q

What foods should this patient avoid>?

A
  • Nutritional concerns
  • Client needs to eat
    -specific proteins,

restrictions of
anticipate sodium and potassium
restrictions

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39
Q

What is the the recommended daily sodium grams intake for a patient with Acute Kidney Injury?

A

1-3G

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40
Q

What are the 2 compensatory organs for acid-base balance?
A. heart
B. spleen
C. kidney
D. lungs

A

C. kidney
D. lungs

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41
Q

Complications associated with Acute renal failure

A
  • Pericarditis
  • Pleuritic pain
  • Pericardial friction rub
  • Tachycardia
  • Fever

Seizures
* Due to increased BUN
and decreased calcium
and decreased sodium in oliguric phase

  • Anemia
  • Due to bleeding from trauma
  • Due to decreased production of EPO
42
Q

Which of the following cells does the kidney produce when it has perfusion and adequate blood flow?

A. Bile
B. Erythropoietin
C. bone marrow
D. estrogen

A

B. Epoetin

Epoetin injection is a man-made version of human erythropoietin (EPO). EPO is produced naturally in the body, mostly by the kidneys. It stimulates the bone marrow to produce red blood cells.

If the body does not produce enough EPO, severe anemia can occur.

43
Q

What can occur is the kidneys due to AKI the not producing Erythropoietin?

A. Disseminated intravascular coagulation
B. Anemia
C. Pica
D. Sickle cell anemia

A

B. Anemia

If the body does not produce enough EPO, severe anemia can occur.

44
Q

What is Chronic Kidney Disease

A
  • Progressive deterioration over years
    with slow loss of kidney function
  • chronic kidney disease occurs is if
45
Q

Does CKD get worse overtime?

A. Yes
B. No

A

A. Yes

  • Kidney function decreases over
    time
  • End stage involves deterioration of
    nephrons
46
Q

What are the signs and symptoms of Chronic Kidney Disease

A

OLIGURIA
-azotemia;build up of nitrogen waste
-fluid overload
-Anemia
-pulmonary crackles,
-dependent and generalized edema (anasarca),
-decreased oxygenation
- (low peripheral oxygenation or SpO 2), -confusion,
-increased respiratory rate,
-dyspnea
-tachycardia
-bounding pulse
-hypertension
-black, tarry stools [melena]).
-uremic frost

47
Q

Characteristics of uremia?

A
48
Q

Prevention of Kidney and Urinary Problems

A

e alert to the general appearance of your urine. Note any changes in its color, clarity, or odor.
* Changes in the frequency or volume of urine passage occur with changes in fluid intake. More frequent or infrequent voiding not associated with changes in fluid intake may signal health problems.
* Any discomfort or distress with the passage of urine is not normal. Pain, burning, urgency, aching, or difficulty with initiating urine flow or complete bladder emptying is of some concern. Report such symptoms to your primary health care provider.
* The kidneys need 1 to 2 L of fluid a day to flush out your body wastes. Water is the ideal flushing agent.
* Avoid sugary, high-calorie drinks; they provide low-quality calories that contribute to weight gain and sugar-induced urination.
* Changes in kidney function are often silent for many years. Periodically ask your primary health care provider to measure your kidney function with a blood test (serum creatinine) and a urinalysis.
* If you have a history of kidney disease, diabetes mellitus, or hypertension (high blood pressure) or a family history of kidney disease, you should know your serum creatinine level and your glomerular filtration rate (either estimated from serum creatinine or measured with a 24-hour creatinine urine collection). At least one
checkup per year that includes laboratory blood and urine testing of kidney function is recommended.
* If you are identified as having decreased kidney function, ask about whether any prescribed drug, diagnostic test, or therapeutic procedure will present a risk to your current kidney function. Evaluate the contribution of diet to risk for kidney disease with your primary health care provider or a registered dietitian nutritionist. Check out all nonprescription drugs with your primary health care provider or pharmacist before using them.

49
Q

What is the best way to monitor patient weight?

A. Urine output
B. Skin turgor
C. daily weights
D. patients self report

A

C. daily weights

Managing Fluid Volume
* Weigh the patient daily at the same time each day, using the same scale, with the patient wearing the same amount and type of clothing, and graph the results.
* Observe the weight graph for trends (1 L of water weighs 1 kg).
* Accurately measure all fluid intake and output.
* Teach the patient and family about the need to keep fluid intake within prescribed restricted amounts and to ensure that the prescribed daily amount is evenly distributed throughout the 24 hours.
* Monitor for these symptoms of fluid overload at least every 4 hours during critical illness:
* Decreased urine output
* Rapid, bounding pulse
* Rapid, shallow respirations
* Presence of dependent edema
* Auscultation of crackles or wheezes
* Presence of distended neck veins in a si ing position * Decreased oxygen saturation
* Elevated blood pressure
* Narrowed pulse pressure
* Assess level of consciousness and degree of cognition.
* Ask about the presence of headache or blurred vision.

50
Q

What is the main treatment for chronic kidney disease.
A. fluid challenges
B. dialysis
C. diuretics
D.antihypertensives

A

B. dialysis

51
Q

Is it a common finding to have anemia with CKD
A. yes
B.no

A

A. yes

52
Q

Nursing interventions for fluid overload

A

administer diuretics as prescribed

53
Q

Nursing intervention for decreased cardiac function

A

-prioritize rest
-administer antihypertensive meds as prescribed
-administer diuretics
-administer epoetin

54
Q

nursing interventions for weight loss

A

-monitor intake and ouput
-take daily weights
-low sodium diet
-diuretic use

55
Q

Nursing intervention for decreasing risk for injury

A

-decreased use of a urinary catheter
-monior skin integrity

56
Q

What electrolytes should restrict for a patient with CKD

A

-sodium
-potassium
-phosphate

57
Q

should you administer lisinopril and spirinolactone for a pt with ckd

A

no , they are potassium sparing meds , EKG -PEAK T WAVES

58
Q

As ckd progress they will neeed….

A

dialysis and kidney replacement

59
Q

The poctor prescribed an ECG for a patient with AKI ?
What would you suspect the ECG to show?

A. prolonged pr waves
B. Elevated st waves
C. Peak T waves
D. No qt wave

A

C. Peak T waves
due to hyperkalemia

60
Q

What is Hemodialysis and its function?

A

a medical procedure used to excrete waste products from the blood.

  • Most common
  • Removes excess fluids and wastes
  • Restores chemical and electrolyte balance * Passes blood via artificial semipermeable membrane
61
Q

What is the first thing you need prior to starting Hemodialysis for a patient with CKD?

A

Arteriovenous fistula
* AV graft

(connection of the vein and artery)

-VITALS BEFORE AND AFTER
-HOLD MORNING MEDS

62
Q

Complications of fistulas and grafts

A

Infection,
thrombosis,
hemorrhage,
bacteremia,

distal ischemia d/t shunting of
the arterial blood, Pain radiation**

aneurysm at the fistula site

63
Q

Signs and symptoms of Distal Ischemia?

A

Distal ischemia is a rare complication in patients undergoing placement of an arteriovenous (AV) fistula or AV graft.

Cold hands, numbness and pain during or outside the dialysis process

64
Q

Before starting the Hemodialysis treatment what should you assess for in the fistula?

A

- Palpate for the thrill
-auscultate for the bruit

ALSO- monitor labs prior to administration, if potassium is at a 3 , we may have to hold hemodialysis tx

65
Q

Should you take blood pressure on a AV fistula or do a venipuncture on that arm?

A. yes
B. NEVER

A

B. NEVER

66
Q

Would you administer an antihypertensive medication prior to hemodialysis?

A. No
B. Yes

A

A. No

YOU WILL BOTTOM THE PATIENT OUT

common findings after hemodialysis is a decrease in fluid volume and blood pressure.

67
Q

Is heparin used in the hemodialysis procedure?
A. No
B. Yes

A

B. Yes

to decrease clots in the machine and to thin out blood,
monitor for hemorhage

68
Q

What should you monitor for a patient taking Heparin?

A

Hemmroahge
- tachycardia and hypotension

69
Q

What should you always have an order for when your patient is taking Heparin?
-hint antidote

A

Protamine Sulfate

70
Q

Is Hemodialysis and inpatient or outpatient procedure? and how often is this procedure done a week?

A

3x a week, outpatient procedure

71
Q

Your patient has chronic kidney disease is scheduled for hemodialysis procedure at 16:00. His labs came back and his potassium serum levels are at a 2.9. What is the nurses priority action?
A. call the HCP and to hold the procedure
B. prep him for the procedure
C. administer spironolactone
D. continue his low potassium diet

A

A. call the HCP and to hold the procedure

72
Q

What levels of potassium warrant concern?
A. 3.4
B. 4.5
C. 4.9
D. 6.6

A

D. 6.6

6 IS TOO HIGH, get ready to administer furosemide

73
Q

Is a partner required for Hemodialysis

A

Yes two nurses

74
Q

Your patient has chronic kidney disease is scheduled for hemodialysis procedure at 16:00. His labs came back and his potassium serum levels are at a 6.6. What is the nurses priority action?
A. call the HCP and to hold the procedure
B. prep him for the procedure
C. question the order
D. continue a high potassium diet

A

B. prep him for the procedure

  • the procedure is warranted , because his potassium is high.
    -This warrants no concern for the nurse, prepare him for the procedure
    -high protein diet as well if they are about to start hemodialysis
75
Q

What is the major complication of Hemodialsis?

A

Monitor for Disequilibrium Syndrome

this can occur during or after hemodialysis procedure

76
Q

What is Disequillibrum Syndrome?

A

a neurological deteriotation associated with Cerebral edema and increase ICP

It is thought to be the result of a rapid reduction in electrolytes and other particles.

77
Q

What are the signs and symptoms of disequilibrium syndrome

A
  • nausea and vomitting
    -decreased level of consciousness
    -seizures
    -coma
    -death
    -restlessness
    -irritability
    -blurry vision
    -hypotension
    -headaches
78
Q

Mild form of Disequillibrium syndrome s/s

A

A mild form of disequilibrium syndrome includes symptoms of nausea, vomiting, headaches, fatigue, and restlessness.

-It is thought to be the result of a rapid reduction in electrolytes and other particles.

Nursing intervention
Reducing blood flow at the onset of symptoms can prevent this syndrome.

79
Q

Nursing intervention for post hemodialysis disequilibrium syndrome

A

Reducing blood flow at the onset of symptoms can prevent this syndrome.
SLOW DOWN INFUSION
Notify physician

80
Q

What is Peritonieal dialysis

A

hypertonic fluid that is inserted through a catheter in peritoneal spaces which covers the abdominal organs.

1-3L of fluid instilled into abdomen, allowed to dwell for period of
time then drained

-the hypertonic fluid draws out all excess fluid and waste into a bag.

-the bag is placed in lower the abdomen to promote drainage by gravity

81
Q

Can the patient perform Peritoneal dialysis at home?
A. Yes
B. No

A

A. Yes , this procedure can be preformed 7 days a week

82
Q

should you place the hypertonic diasylate fluid bad on ice prior to administration?

A. yes
B.no

A

B.no

Cold dialysate increases discomfort. Warm the dialysate bags before instillation by using a heating pad to wrap the bag or by using the warming chamber of the automated cycling machine.

Microwave ovens are not recommended for warming dialysate.

WARM THE BAG prior to administration

83
Q

What is the reason as to why your patient needs to have their bowels empty before peritoneal dialysis?SELECT ALL THAT APPLY

A. to reduce the change of neurological disorders
B. to avoid bowel perforation
C. to avoid disequilibrium syndrome
D. To avoid the sign of the Turner
E. to increase functionality of the outflow

A

B. to avoid bowel perforation
E. to increase functionality of the outflow

  • give an enema before stating peritoneal dialoysys may also prevent flow problems

ther complications of PD include bleeding, which is expected when the catheter is first placed, and bowel perforation, which is serious.

When PD is first started, the outflow may be bloody or blood tinged. This condition normally clears within a week or two.

After PD is well established, the effluent should be clear and light yellow. Observe for and document any change in the color of the outflow. Brown-colored effluent occurs with a bowel perforation. If the outflow is the same color as urine and has the same glucose level, a bladder perforation is probable. Cloudy or opaque effluent indicates infection.

84
Q

Signs and symptoms of Bowel perforation

A

Brown-colored effluent occurs with a bowel perforation.

If the outflow is the same color as urine and has the same glucose level, a bladder perforation is probable.

85
Q

Your patient has had his peritoneal catheter placed 5 days ago . He comes into the emergency room due to his dialsyte effluent being blood-tinged. What is the nurse’s priority action?
A.Notify physician
B. Teach the client that this is a normal finding.
C. initiate hemodialysis procedure
D. Send patient to cath lab

A

B. Teach the client that this is a normal finding.

When PD is first started, the outflow may be bloody or blood-tinged. This condition normally clears within a week or two.

86
Q

Your patient who has just started peritoneal dialysis has been reporting of pain. What is the nurses priority intervention??
A. Notify the physician
B. Administer Tylenol 325Mg
C. Administer lactulose
D. instruct the patient to stop the peritonel dialysis when ever he feels pain

A

B. Administer Tylenol 325Mg

Pain during the inflow of dialysate is common when patients are first started on PD therapy. Usually this pain no longer occurs after a week or two of PD

87
Q

What position should the patient be in during Peritoneal Diaysis SELECT ALL THAT APPLY
A. prone
B. supine
C. low fowlers

A

B. Supine
C. low fowlers

Low Fowler or supine position to reduce abdomen pressure

NO PRONE POSISTION, when changing tubing place mask on yourself and patient

88
Q

When appreciating the catheter site is a clean or sterile technique required?

A. clean
B. sterile

A

B. sterile

89
Q

Possible complications for Peritoneal Dialysis- s/s

A

Loss of protein
** Peritonitis – Look for cloudy dialysate**, -abdominal pain,
-rigid board-like
abdomen,
-fever

  • Pain * Exit site and tunnel infections * Poor dialysate flow * Fibrin clot formation * Dialysate leakage * Bleeding * Bowel perforation
90
Q

What is the first sign of Peritonitis for a patient on Peritoneal dialysis?
A. fever
B. cloudy effluent
C. fatigue
D. Dyspnea

A

B. cloudy effluent
Cloudy or opaque effluent is the earliest indication of peritonitis. Examine all effluent for color and clarity to detect peritonitis early.

91
Q

What is the nurses next priority action when she suspects peritonitis?

A. notify the provider
B. Send the specimen to the lab
C. Request an order for antibiotics
D. Increase intravenous fluid

A

B. Send the specimen to the lab

When peritonitis is suspected, respond by sending a specimen of the dialysate outflow for culture and sensitivity study, Gram stain, and cell count to identify the infecting organism.

92
Q

What outflow would warrant immediate attention during peritneal dialysis
A. warm outflow
B. cloudy outflow
C. yellow outflow
D. clear outflow

A

B. cloudy outflow

FIRST SIGN OF INFECTION

93
Q

Nursing assessments for patient during and after PD

A
  • monitor for constipation due to fluid loss during procedure
    -decrease protein intake
94
Q

Patient care for peritoneal Dialysis

A

*Mask yourself and your patient. Wash your hands.
* Put on sterile gloves. Remove the old dressing. Remove the contaminated gloves.
* Assess the area for signs of infection, such as swelling, redness, or discharge around the catheter site.
* Use aseptic technique:
* Open the sterile field on a flat surface and place two precut 4 × 4– inch gauze pads on the field.
* Place three co on swabs soaked in povidone-iodine or other solution prescribed by the nephrology health care provider on the field. Put on sterile gloves.
* * Use co on swabs to clean around the catheter site. Use a circular motion starting from the insertion site and moving away toward the abdomen. Repeat with all three swabs.
* * As an alternative (if recommended by the nephrology health care provider or clinic), cleanse the area with sterile gauze pads using soap and water. Use a circular motion starting from the insertion site and moving away toward the abdomen. Rinse thoroughly.
* * Apply precut gauze pads over the catheter site. Tape only the edges of the gauze pads.

95
Q

Kidney transplant post op nursing assement

A
  • monitor urine output
    -less than 30 , warrants immediate attention
    -monitor for signs of organ rejection
    -monitor for infection
    -monitor for hemmroage
96
Q

What are the s/s of Organ rejection

A

-pain
-fever
-weight gain
-hypertension
-increased BUN
-INCREASED CREATININE
-WBC elevation indicating infection and rejection
-oliguria

97
Q

What should the patient teaching post kidney transplant?

A
  • monitor for signs of kidney rejection
    -monitor for signs of infection
    -NO CONTACT SPORTS
98
Q

What type of medication will a patient take for life after a kidney replacement?

A. immunosuppressant
B. NSAIDS
C. Anti depressants
D. Anti hypertensive

A

A. immunosuppressant like cyclosporine

99
Q

Care for AV line

A
  • Do not take blood pressure readings using the extremity in which the vascular access is placed.
  • Do not perform venipunctures or start an IV line in the extremity in which the vascular access is placed.
  • Palpate for thrills and auscultate for bruits over the vascular access site every 4 hours while the patient is awake.
  • Assess the patient’s distal pulses and circulation in the arm with the access.
  • Elevate the affected extremity after surgery.
  • Encourage routine range-of-motion exercises.
  • Check for bleeding at needle insertion sites.
  • Assess for indications of infection at needle sites.
  • Instruct the patient not to carry heavy objects or anything that compresses the extremity in which the vascular access is placed.
  • Instruct the patient not to sleep with his or her body weight on top of the extremity in which the vascular access is placed.
100
Q

A client who performs continuous ambulatory peritoneal dialysis at home reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the priority nursing action?
A. Remove the peritoneal catheter.
B. Notify the nephrology health care provider.
C. Obtain a sample of effluent for culture and sensitivity.
D. Teach the client that effluent should be clear or slightly yellow.

A

C. Obtain a sample of effluent for culture and sensitivity.

101
Q

Nursing Care for patient during Peritoneal Dialysis

A

Weigh the patient, always on the same scale, before the procedure and at least every 24 hours while receiving treatment.

Baseline laboratory tests, such as electrolyte and glucose levels, are obtained before starting PD and repeated at least daily during the PD treatment.

In the hospital se ing, especially with a new access, continually monitor the patient receiving PD fluid exchanges. Take and record vital signs every 15 to 30 minutes. Assess for respiratory distress, pain, or discomfort. Check the dressing around the catheter exit site every 30 minutes for wetness during the procedure. Monitor the prescribed dwell time and initiate outflow. Assess blood glucose levels in patients who absorb glucose.

Observe the outflow patt ern (outflow should be a continuous stream after the clamp is completely open). Measure and record the total amount of outflow after each exchange. Maintain accurate inflow and outflow records when hourly PD exchanges are performed. When outflow is less than inflow, the difference is retained by the patient during dialysis and is counted as fluid intake. Weigh the patient daily to monitor fluid status.

NUR 265 ADVANCED MED SURG (53 decks)

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