Module 2 Med-Surg I.txt

Dehydration is the clinical consequences of negative fluid balance (i.e., of fluid intakes that fail to match fluid losses.) Dehydration is marked by thirst, orthostatic hypotension, tachycardia, elevated plasma sodium levels, hyperosmolality, and in severe cases, cellular disruption, delirium, falls, hypertermia, medication toxicity, renal failure, or death.

Systemic changes include: decrease in the number of nephrons (filtering units), decrease in the overall amount of kidney tissue, the blood vessels supplying the kidneys harden, and the kidneys filter blood more slowly. The implications for the elderly are: the decreased muscle tone and elasticity of the ureters, bladder, urinary sphincter, and surrounding structures result in incontinence; proststic hyperplasia in the male can cause urinary retention; decrease in nephrons results in decrease glomerular filtration rate to cause higher BUN and Creatinine levels in the blood; retention or decreases in renal concentration may cause nocturia.

For women: wash from front to back; for men; use a circular motion from urethra outward. Begin voiding. After stream begins, collecta 30 - 60 mL specimen. Maintain sterility: do not touch the inside of the container or the lid. Place the lid on the container.

Preparation: Obtain history of allergies (esp. shellfish or iodinated dye), Ensure baseline BUN and creatinine is available, Ensure a signed consent form is on the chart, NPO 8 hrs before the procedure, some patients may require a laxative the evening before the test to ensure visualization. Post-procedure Care: Encourage increased fluid intake, monitor vital signs and I&O, observe for reactions to contrast media (rash, nausea, hives).

• Urinalysis
• Creatinine clearance
• Urine culture (clean catch midstream)
• Concentration test
• Residual urine
• Protein determination
• Urine cytology
• 24 hour urine test
• BUN
• BMP
• CBC
• Creatinine
• Uric Acid
• Sodium
• Potassium
• Calcium
• Phosphorus
• Bicarbonate
• KUB (kidneys, ureters, and bladder) X-Ray
• IVP (excretory urogram)
• Nephrotomography
• Retrograde pyelogram
• cystogram
• renal arteriogram (angiogram)
• Ultrasound
• CT scan
• MRI
• Renal biopsy
• Urodynamics

The Renin-Angiotensin system - Renin has the capability of activating critical events. For example, when sensing low volumes of distal tubular filtration, renin release by the juxtaglomerular cells will initiate the formation of angiotensin I, which converts to angiotensin II. Angiotensin-converting exzyme (ACE) is the catalyst in the conversion of angiotensin I to angiotensin II. The cumulative action of these three potent chemicals cause vasoconstriction and yields an increase in blood pressure. Oftentimes, renin release is a direct result of pathology that would be further complicated by its release. One example of a pathology that activates the renin-angiotensin cycle is congestive heart failure with associated decrease in renal perfusion or glomerular filtration. Renin release is detrimental and obliges timely intervention with agents such as diuretics, ACE inhibitors, or other antihypertensive medications.

• Stress incontinence is loss of urine with increased intra-abdominal pressure without detrusor contraction.
• Urge incontinence is precipitous loss of urine preceded by a strong urge to void, with increased intravesical pressure and detrusor contraction.
• Overflow incontinence is loss of urine because of chronic urinary retention or secondary to a flaccid bladder.
• Functional incontinence is normal bladder control with problems getting to the toilet in time (usually because the client is older and not able to move around as fast).
• Total incontinence is the total loss of bladder control.
• Acute and chronic is voiding then still feeling the urge to void because the bladder is not completely empty.

• Acute renal failure is the sudden and significant decrease in the kidneys' filtration capabilities and, within hours or days, an increase in thelevels of creatinine and other waste products in the systemic circulation. The causes of acute renal failure are prerenal, renal, and postrenal.
• Chronic renal failure is a progressive and irreversible decline in renal function, and requires dialysis. Common causes of chronic renal failure are diabetes and hypertension.

• Peritoneal dialysis is when the capillaries of the peritoneal membrane allow solute clearance down a concentration gradient between the instilled dialysate and the plasma. Fluid removal is by osmotic gradient with dialysate dextrose concentration providing the higher osmotic pressure. Capillary pore size will allow some protein loss but is not large enough to allow phosphate clearance. Phosphate binding is required. PD involves: filling the peritoneal cavity with a prescribed volume of peritoneal diasylate, allowing it to dwell for a prescribed period of time, then draining and discarding the effluent (waste materials). Continuous ambulatory peritoneal dialysis (CAPD) requires manual dialysate instillation and removal on a predetermined schedule.
• Hemodialysis is the use of an artificial kidney the clear urea, metabolic wastes, toxins, and excess fluid from the blood and is used to treat end-stage renal failure, transient renal failure, and some cases of poisoning or drug overdose. The technique of hemodialysis separates solutes by differential diffusion through a cellophane membrane placed between the blood and the dialysate solution, and involves: establishing access to circulation, anticoagulating the patient's blood to prevent extracorporeal clotting, pumping the blood to a dialysis membrane, adjusting the diffusion of solutes from the blood into a buffered dialysate solution, returning the cleansed blood and buffered blood to the patient. Each treatment last 3 to 4 hours several times per week.

Treat the underlying cause of ARF, keep the patient informed of the disease process and treatment plan, determine the patients understanding of medical terminology need to understand ARF, fluid replacement in primary hypovolemia and high output failure in the recovery phase, offer fluids regularly, fluid restriction in low output failure and hypervolemia, intermittent hemodialysis or continuous renal replacement therapy, diuretics (as appropriate and with evidence of tubular response), maintain accurate I&O records and obtain daily weight, monitor respiratory status (anticipate acute changes, particularly with fluid challanges or with acutely diminished urine output), monitor blood chemistries and respond appropriately, manage serum potassium, and mainatin BP control both hypertension and hypotension.

Facilitate communication of concerns or feeling between client and family or between family members; maintain fluid balance utilizing fluid restriction, diuretics, and dialysis; weight will remain within 2 to 3 kg of dry weight; maintain electrolyte and mineral balance utilizing dietary restrictions, phosphate binders, pharmacology therapy, or dialysis; provide adequate nutrition; manage anemia with recombinant erythropoietin and blood transfusions; manage hyperglycemia; manage patent and infection-free dialysis access and prevent infection; maintain integrity of dialysis access.

• Maintain fluid balance by monitoring I&O and providing expedient replacement.
• Monitor laboratory studies for grapt function and electrolyte balance.
• Monitor for abrupt decreases in urine output and abrupt increase in pain or swelling at the graft site, as this may indicate renal vascular thrombosis or acute rejection.
• Monitor wound drainage for signs of uretral anastomosis failure.
• Adhere to the immunosuppression schedule and facilitate accurate timing of phlebotomy blood drawing samples for related drug levels.
• Monitor blood glucose and anticipate changes related to high-dose glucocorticoids.
• Arrange for a supply of medications prior to discharge to prevent any disruption in immunosuppression.
• Teach the patient medication management, follow-up protocols, signs of transplant rejection or infection, and appropriate response. importance of adequate hydration, and infection prevention.
• Offer the patient support during periods of delayed graft function or graft failure.
• Arrange postdischarge follow-up appointments.

GFR is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time. The glomerulous is the main filter of the nephron and is located within the Bowman's capsule. Electrolytes pass through NA+, K+, Ca2+, Mg2+, Cl-, HCO3-, and H+, Water (nitrogenous wastes), small hormones (not large hormones). Blood cells, plasma proteins, Albumin, Protein too large to filter through capillary walls do NOT pass through. Blood pressure affect the GFR.

The presence of increased amounts of nitrogenous waste products. especially urea, in the blood

Problems affecting the flow of blood before it reached the kidneys (decreased blood flow to the kidneys). Examples: severe dehydration, prolonged hypotension, renal ischemia, renal emboli, or septic/cardiogenic shock.

Problems affecting the movement of urine out of the kidneys (obstruction to urine flow). Examples: Prostatic hyperplasia, bladder outlet obstruction.

Problems with the kidney itself that prevent proper filtration of blood or production of urine. Examples: Glomerulonephritis, toxic injury to the kidneys (drugs or poisons).

within the kidneys

outside the kidneys

A cytokine made by the kidneys that stimulates the proliferation of red blood cells.

Monitor vital signs and fluid balance; ensure adequate I&O; monitor electrolytes, WBC, BUN, and creatinine; provide adequate pain management; assist with hygiene and appropriate knowledge of disease.

The patient is prepared for surgery according to protocol. Withhold aspirin or other medications that may cause postoperative hemorrhage. Assure family that in most instances the body will adapt to functioning with only one kidney. Postoperatively, monitor vital signs; administer analgesics, and report any excessive bleeding. Dressing changes are performed according to protocol. Fluid I&O, body weight, and electrolytes are monitored closely. The patient is assessed for postop complications. The patient is encouraged to breathe deeply using a spirometer and to cough to prevent atelectasis (collapsed lung). Antithrombotic hose are applied. Early ambulation is encouraged. Discharge teaching and follow-up.