NUR 425 Exam 2

What does absolute neutrophil count measure?

The total number of neutrophils in the blood

Which lab test is used to monitor the intrinsic pathway?

PTT (partial prothrombin time)

Which lab test is used to monitor the extrinsic pathway?

PT (prothrombin time)

aPTT (activated partial thromboplastin time)

30-40 seconds

INR

1 or less

PTT (partial prothrombin time)

60-70 seconds

PT (prothrombin time)

10-13 seconds

What drug does PT (prothrombin time) monitor?

Warfarin (Coumadin)

What drug does PTT and aPTT monitor?

Heparin

Red Blood Cell (RBC) Count

Females: 3.61 - 5.11 million/mm3 (4) Males: 4.21 - 5.81 million/mm3 (5)

Hematocrit

Females: 36% - 48% (39) Males: 42% - 52% (45)

Hemoglobin

Females: 11.7 - 15.5 g/dL (13) Males: 14 - 17.3 g/dL (15)

White Blood Cell (WBC) Count

4.50 - 11.1 103/mm3

Absolute Neutrophil Count (ANC)

1.5 to 8.0 (1,500 to 8,000/mm3)

Platelets

150,000 - 450,000/µL

What does a WBC shift to the left mean?

-Indicates that more immature cells are present in the blood than normal -Occurs with acute infection, inflammation, or some other significant physical stress

What is anemia?

Occurs when there is a reduction in the oxygen-carrying capacity through either fewer RBCs or a reduction in hemoglobin

What are symptoms of decreased hematocrit?

-Shortness of breath -Tachypnea -Tachycardia -Pallor -Fatigue -Dizziness

What are dietary sources of iron?

-Meat (especially red meat) -Dark green leafy vegetables (spinach, broccoli, peas) -Beets -Dried beans -Iron-fortified breakfast cereals and breads -Cream of Wheat -Ingesting citrus fruits such as oranges or grapefruits increases the vitamin C intake and may improve iron absorption

What are clinical manifestations of iron-deficiency anemia?

-Fatigue -Pallor -Tachycardia -Tachypnea -Glossitis (smooth, shiny tongue) -Koilonychia (spoon-shaped nails)

How is iron-deficiency anemia diagnosed?

-A complete blood count (CBC) demonstrates decreased hemoglobin and hematocrit levels -Serum ferritin levels less than or equal to 100 ug/L indicate IDA 100% of the time -Additional diagnostic studies to confirm IDA include serum iron, total iron-binding capacity (TIBC), serum transferrin receptors, and mean corpuscular volume (MCV)

What teaching do you need to provide to a client with iron-deficiency anemia?

-Dietary sources of iron -Immediately report any signs of bleeding, increasing fatigue, or shortness of breath. -Daily iron supplements must be taken as prescribed. -Dangers of lead exposure -Prenatal teaching about iron intake

What are dietary sources of vitamin B12?

-Meat -Seafood -Eggs -Dairy products

What are clinical manifestations of vitamin B12 anemia?

-Fatigue -Pallor -Tachycardia -Tachypnea -Shortness of breath -Dizziness -Glossitis -Neurological deficits: •Symmetric paresthesia of feet and fingers •Lhermitte's sign •Confusion •Depression •Impaired taste •Impaired balance •Visual disturbances •Tinnitus

How is vitamin B12 anemia diagnosed?

-History and physical examination -Vitamin B12 serum assay blood test

What population is at increased risk of deficiency and may need to take a daily supplement of vitamin B12?

-Long-term vegans/vegetarians -Those of low socioeconomic status

What are clinical manifestations of folic acid deficiency?

-Fatigue -Gray hair -Mouth sores -Swollen tongue -Forgetfulness -Depression -Appetite loss -Difficulty concentrating -Birth defect -Poor growth

What are dietary sources of folic acid?

-Dark green vegetables -Dried beans, legumes -Fortified grains (breads, cereal) -Nuts -Bran -Yeast

What teaching do you need to provide to a client with folic acid deficiency?

-Dietary sources of folate/folic acid -Immediately report any clinical manifestations of fatigue, shortness of breath, dizziness, and confusion. -Prenatal teaching -Need for supplementation

What teaching do you need to provide to a client with sickle cell anemia?

-Pathophysiology of disease -Infection prevention measures -Avoid cold temperatures and wearing tight, restrictive clothing. -Avoid high altitudes and depressurized airplanes. -Avoid dehydration. -Avoid overexertion. -Maintain activities of daily life within prescribed limitations. -Risk of more frequent sickle cell crises during pregnancy. -Fetal complications -Genetic counseling

What are risk factors for sickle cell anemia?

-The sickle cell trait (SCT) is a genetic mutation that must be present in both parents in order for this form of the disease to manifest in offspring -Parents who carry this gene have a one in four chance of producing a child with sickle cell anemia -Precipitating factors include dehydration, cold temperatures, infection, and environments with low oxygen tension, such as depressurized airplane cabins and high mountains

What are clinical manifestations of sickle cell anemia?

-Fatigue -Pallor -Shortness of breath -Vasoocclusion of blood vessels resulting in pain and swelling -Pain usually occurs in the joints, bones, chest, and abdomen -Growth and developmental delays -Hand-food syndrome

What are priority nursing actions for sickle cell anemia?

-Administer oxygen. -Provide aggressive hydration. -Administer pain medication. -Administer blood transfusions. -Administer antipyretics. -Provide supportive measures.

What is the treatment for sickle cell anemia crisis?

Hydration Oxygenation (comes first) Pain relief

What are clinical manifestations of aplastic anemia?

-Decreased RBCs: Fatigue, shortness of breath, tachycardia, pallor, dizziness, and headache -Decreased WBCs: Increased susceptibility to infections, as well as frequent and prolonged infections -Thrombocytopenia: Unexplained and increased incidence of bruising, nosebleeds, gum bleeding, and prolonged bleeding from cuts and other injuries

What teaching do you need to provide to a client with aplastic anemia?

-Avoid exposure to potential infection (individuals with acute infection, crowded places). -Report all temperature elevations. -Avoid activities with the potential for trauma or injury. -Clinical manifestations of anemia -Nutritional intake

What are clinical manifestations of thrombocytopenia?

-Easy bruising and petechiae -Bleeding may occur from the nose, around the gums, or from the gastrointestinal tract

What are priority nursing actions for thrombocytopenia?

-Implement bleeding precautions (RANDI) -Minimize blood loss from lacerations or venipuncture. -Avoid intramuscular injections. -Avoid rectal temperatures, enemas, suppositories, and douches. -Provide a safe environment. -Use minimal inflation when assessing blood pressure. -Minimize blood draws.

What are safety interventions for thrombocytopenia?

Bleeding precautions

What are risk factors for leukemia?

-Genetic anomalies -Down's syndrome -Exposure to radiation or benzene -Chemotherapeutic agents and/or radiation therapy -Smoking -White males over the age of 60

What are clinical manifestations of leukemia?

Anemia: Decreased hemoglobin, fatigue, pallor, weakness, and shortness of breath, as well as bruising, petechiae nosebleeds, and bleeding gums from the decreased number of platelets Neutropenia: Risk for infection, low-grade fevers Thrombocytopenia: Risk for bleeding

What are diagnostic tests for leukemia?

-CBC -History and physical examination -Bone marrow biopsy -Genetic testing

What are priority nursing actions for leukemia?

-Administer chemotherapy as prescribed. -Institute neutropenic precautions. -Prophylactic use of antibiotics, antivirals, and antifungals as ordered -Administer IV antibiotics. -Symptom management (nausea/vomiting/diarrhea, ulcerations of the mouth) -Administer ordered blood products.

What teaching do you need to provide to a client with leukemia?

-Neutropenic precautions -Clinical manifestations of anemia -Manifestations of thrombocytopenia -Bleeding precautions -Diagnosis of leukemia -Adverse reactions of chemotherapy or radiation -Possibility of sterility

What are clinical manifestations for malignant lymphoma?

-Painless swelling of the lymph nodes in the neck, underarm, and groin -Low-grade fevers for no apparent reason -Drenching night sweats -Unexplained weight loss of more than 10% in less than 6 months -Fatigue (known as the "B symptoms") -Generalized pruritus, or itching, with pronounced excoriation from scratching is present in a large percentage of patients presenting with Hodgkin's disease (HD)

What teaching do you need to provide to a client with malignant lymphoma?

-Disease process -Risk of infection -Maintaining treatment schedules -Encourage frequent rest periods. -Dietary intake -Clinical manifestations of potential complications -Possibility of sterility

What are clinical manifestations of multiple myeloma?

-Fatigue -Weakness -Bone pain -Recurrent infections -Weight loss -Paresthesia

What does the nursing assessment include for multiple myeloma?

-Vital signs -Fatigue, pallor, and shortness of breath -Pain -Paresthesias -Intake and output -Serum and urine calcium -Serum blood urea nitrogen (BUN) and creatinine

What teaching do you need to provide to a client with multiple myeloma?

-Immediately report any clinical manifestations of fatigue, shortness of breath, dizziness, or confusion. -Report any sudden onset of severe pain or new location, especially of back pain, which could indicate a pathological fracture. -Report changes in sensation, increased numbness and tingling, or changes in motor function. -Instruct in the use of nonpharmacological pain management methods, such as music, relaxation, deep breathing, imagery, distraction, and progressive muscle relaxation.

What effect does renal insufficiency have on RBC count?

Decreases RBC count

What are examples of potential nephrotoxic substances?

-Antibiotics -Analgesics: NSAIDS -Other medications: ACE inhibitors, benzodiazepines, contrast media, diuretics -Substances: Cocaine, gold, heroin, lead, mercury

What is anuria?

-Less than 100-mL urine output/24 hr -Clinical significance of abnormal finding: End-stage renal disease, acute renal failure, urinary tract obstruction

What is dysuria?

-Difficulty or pain with urination -Clinical significance of abnormal finding: Urinary tract infection, cystitis (bladder infection)

What is enuresis?

-Involuntary urination at night -Clinical significance of abnormal finding: Lower urinary tract disorder

What is frequency?

-Increase in incidence of voiding, usually urinating only small amounts with each void -Clinical significance of abnormal finding: Bladder inflammation, excessive fluid intake, urinary retention

What is hematuria?

-Presence of blood in the urine -Clinical significance of abnormal finding: Cystitis or other inflammation in the urinary tract, calculi, cancers of the urinary tract, renal disease, bleeding disorders, medications such as anticoagulants

What is hesitancy?

-Difficulty starting the flow of urine -Clinical significance of abnormal finding: Urethral obstruction, enlargement of the prostate gland (benign or malignant)

What is incontinence?

-Inability to voluntarily control micturition -Clinical significance of abnormal finding: Bladder infections, trauma to the external sphincter, neurogenic bladder, trauma to the nerve innervating the urinary tract structures

What is nocturia?

-Frequent urination at night -Clinical significance of abnormal finding: Heart failure, renal disease, bladder obstruction, consumption of excessive fluids late at night

What is oliguria?

-Decreased urine output; less than 400-mL urine output/24 hr -Clinical significance of abnormal finding: Shock, end-stage renal disease, acute kidney injury, severe dehydration, blood transfusion reaction

What is polyuria?

-Increased urine output; greater than 2,000-mL urine output/24 hr -Clinical significance of abnormal finding: Excessive fluid intake, diabetes insipidus, diabetes mellitus, diuretic medications, diuresis phase of chronic renal failure

What is renal colic?

-Pain radiating to the perineal or groin area -Clinical significance of abnormal finding: Ureter spasm during passage of calculi, ureter obstruction

What is retention?

-Inability to completely empty the bladder of urine -Clinical significance of abnormal finding: Normal finding briefly after childbirth, pelvic surgery, and removal of indwelling catheter Prolonged/abnormal related to neurogenic bladder, obstruction or stricture of the urethra

What is urgency?

-Sudden onset of the urge to void immediately -Clinical significance of abnormal finding: Medications, pelvic organ prolapse, cystitis, UTI

Serum Creatinine

0.5 - 1.2 mg/dL

Blood Urea Nitrogen (BUN)

8 - 21 mg/dL

BUN/Creatinine Ratio

10:1 to 20:1

Uric Acid

3.5 - 8 mg/dL

Bicarbonate

22 - 26 mEq/L

Sodium

135 - 145 mEq/L

Potassium

3.5 - 5.0 mEq/L

Phosphorus

2.5 - 4.5 mEq/L

Calcium

8.2 - 10.2 mEq/dL

Urine Specific Gravity

1.005 - 1.030

Glomerular Filtration Rate (eGFR)

85 - 110 is ideal > 60 normal < 15 can indicate possible kidney failure

What are clinical manifestations of hyperkalemia?

Cardiac abnormalities -Life-threatening dysrhythmias such as ventricular fibrillation, ventricular tachycardia, or asystole -The initial indication on an ECG is peaked T waves

What does an increased urine specific gravity indicate?

Dehydration

What is a nursing intervention for increased urine specific gravity?

Increase fluids for hydration

What are clinical manifestations of PKD?

-Hypertension -Hematuria -Flank pain -Headaches -Pain in the abdominal area -Manifestations of UTI -Bilaterally enlarged kidneys -Increased abdominal girth -Costovertebral angle tenderness

What are priority nursing interventions for PKD?

-Diet modification consistent with impaired renal function, specifically low potassium, phosphorus, protein, and sodium -Fluid restriction -Administer antihypertensive agents as ordered. -Administer antibiotics as ordered. -Administer pain medication as ordered.

How do you use therapeutic communication with a client who has PKD?

-Provide psychosocial support to client and family -Teach the client and family about prescribed treatments

What are the plan of care goals for a client with PKD?

-Prevent complications -Medication compliance (antihypertensives, antibiotics, etc) -Diet modification -Vital signs within reasonable limits -Absence of infection

What kind of diet should a client with PKD follow?

-Diet modification consistent with impaired renal function, specifically low potassium, phosphorus, protein, and sodium -Diet modification is essential to prevent severe complications from eating foods high in protein, potassium, and phosphorus that the kidneys cannot excrete adequately -Excess sodium intake can cause fluid retention

What teaching do you need to provide to a client with PKD?

-Immediately report clinical manifestations of infection. -Follow prescribed dietary restrictions. -Follow prescribed antihypertensive therapy. -Follow prescribed antibiotics for diagnosed UTIs.

What are risk factors for pyelonephritis?

-Multiple pre-existing UTIs, treated or untreated which may be caused by: +Vesicoureteral reflux +Obstructions such as benign prostatic hypertrophy (BPH), a stricture, or a urinary stone +A long-term indwelling urinary catheter +Pregnancy +Sexual activity in women

What are clinical manifestations of pyelonephritis?

-Signs of infection (fever, chills, nausea, and vomiting) -Back or flank pain -CVA tenderness and enlarged kidneys -Frequent and painful urination, and hematuria

What are clinical manifestations of pyelonephritis in the elderly?

-Fever -Acute dysuria -New or worse urinary urgency or incontinence -Gross hematuria -Suprapubic or costovertebral pain

What are the plan of care goals for a client with pyelonephritis?

-Complications such as damage to renal structures, scarring, and chronic pyelonephritis can be avoided with proper treatment, follow-up care, and prevention -No symptoms associated with pyelonephritis, such as burning or pain on urination, urinary frequency, hesitancy, urgency, nocturia, and hematuria -Self-care efforts and compliance with treatment are evident from improvements in symptoms and reductions in recurrent infections

What are nursing actions for pyelopnephritis?

-Administer prescribed antibiotics as ordered. -Administer prescribed pain medications. -Provide adequate hydration, PO or IV as ordered.

What teaching do you need to provide to a client with pyelonephritis?

-Explain the disease condition to the patient and family. -Instruct the patient and family on how to avoid UTIs. -Take prescribed medications as ordered. -Instruct the patient and family on the importance of rest.

What are complications of pyelonephritis?

-Scarring, chronic kidney disease (CKD), or permanent damage -Multisystem organ failure as a result of septic shock -Changes in mental status, fever, tachycardia, tachypnea, hypotension, oliguria, and leukopenia are the early signs of urosepsis

What are risk factors for acute glomerulonephritis?

-Infections such as recent strep -Immune diseases such as lupus, vasculitis, hypertension, and diabetes

What are clinical manifestations of acute glomerulonephritis?

-Proteinuria -Hematuria -Presence of WBCs and casts in urine -Edema -Decreased urine output (oliguria) -Hypertension -Elevated BUN and creatinine

What teaching do you need to provide to a client with acute glomerulonephritis?

-Overview of the disease process -Prescribed medications -Dietary restrictions -Avoid infections

What is considered the typical treatment for renal cancer?

Radical nephrectomy

What is a radical nephrectomy?

Involves removal of the affected kidney, adrenal gland, and surrounding tissues, such as the fascia, part of the ureter, and the draining lymph nodes

What is the survival rate after undergoing a radical nephrectomy?

With early detection, renal cancer has shown a 60% to 70% 5-year survival

What teaching do you need to provide to a client who is undergoing a radical nephrectomy?

-Avoid lifting >5 lbs -Do not engage in strenuous activity -Understand measures to protect function of remaining kidney (control BP, drink adequate fluids, limit NSAID use, stop smoking) -PO hydration -Cough and deep breathe -Keep dressing clean -Take medications as prescribed

What teaching do you need to provide to a client with renal cancer?

-Teach the patient and family about the condition and any procedures or diagnostic tests. -Teach the patient and family regarding medications. -Provide appropriate resources for counseling regarding the disease process, tests and procedures, changes in body image, and financial concerns

What are postoperative actions following a radical nephrectomy?

-Administer pain medication as ordered. -Administer IV hydration as ordered/encourage PO hydration as ordered. -Encourage respiratory exercises. -Appropriate care of catheters, stents, nephrostomy tubes, or drains -Perform wound care as ordered.

What are clinical manifestations of AKI?

-Signs of volume overload due to decreased urine output: +Edema +Pulmonary edema and shortness of breath +Heart failure and jugular vein distention +Hypertension and dysthymias +Chest pain or pressure -Electrolyte imbalances include: +Increased potassium, phosphorous, BUN/creatinine +Decreased calcium, sodium, and pH +Metabolic acidosis -Anorexia -Nausea -Constipation or diarrhea -Confusion and lethargy -Seizures or coma

What is the goal of nutrition for patients in AKI?

-Provide calories to prevent catabolism despite the restrictions required to prevent electrolyte and fluid disorders and azotemia -If the patient does not receive proper nutrition and calories, then catabolism of body protein will occur, which causes urea, phosphate, and potassium levels to increase

What diet must a client with AKI follow?

-Adequate carbohydrate, protein, and fat are necessary components of the diet -Potassium and sodium are strictly regulated

Why is potassium and sodium strictly regulated in an AKI diet?

-Sodium is restricted to prevent edema, hypertension, and congestive heart failure -Potassium is restricted to avoid the cardiac complications of hyperkalemia

What is a clinical manifestation of the oliguric phase of AKI?

Urine output below 400 mL/day

How is oliguria characterized in the oliguric phase of AKI?

Urine with a fixed specific gravity (between 1.007 and 1.010) and a high sodium concentration (> 40 mEq/L [> 40 mmol/L])

What does a high sodium concentration with a fixed specific gravity indicate in the oliguric phase?

Intrarenal damage that does not respond to the compensatory mechanisms of RAAS

What is increased in the oliguric phase?

-BUN/creatinine -Electrolyte abnormalities -Acidosis -Fluid overload as a result of reduced GFR

How long could the oliguric phase last?

-14 days or longer depending on the initiation of definitive treatment such as dialysis -The longer the oliguric phase lasts, the poorer the prognosis

What are clinical manifestations of CKD?

-Alterations in sodium and fluid: Hypertension, heart failure, and pulmonary edema -Altered potassium excretion: Lethal arrhythmias -Impaired metabolic waste elimination: GI symptoms such as nausea, vomiting, and anorexia and neurological symptoms such as a headache, lethargy, fatigue, confusion, and ultimately, without treatment, seizures and coma -Altered calcium and phosphorus levels: Bone breakdown and osteodystrophies or defective bone development -Decreased acid clearance and bicarbonate production: Result in metabolic acidosis -Endocrine and reproductive dysfunctions: Infertility, amenorrhea, hyperparathyroidism, thyroid abnormalities -Decreased production of erythropoietin: Chronic anemia

What are the priority nursing assessments for CKD?

-Vital signs/SpO2 -Assess pulmonary, cardiac, and peripheral vascular systems. -Monitor laboratory values.

What is an arteriovenous (AV) fistula?

-Used for long-term access for HD -Created by surgical anastomosis of an artery and vein, typically the radial artery and cephalic vein, in the nondominant arm -Maturing the AV fistula occurs when the low-pressure vein becomes accustomed to the higher pressures generated in the artery, which allows adequate blood flow for dialysis

What are possible complications of a localized AV fistula?

-Infection and clotting or thrombosis -Aneurysms -Staphylococcus aureus -Infection and thrombosis can lead to systemic manifestations such as septicemia and embolization

What are risk factors for nephrolithiasis/urolithiasis?

-Decreased water consumption leading to dehydration -Family history -Increased sodium or protein intake

What are clinical manifestations of renal calculi?

-Severe pain, causing distention and obstruction of urine flow -Nausea and vomiting -Upper ureteral stones causing referred pain to the flank -Lower ureteral stones causing lower abdominal, genital pain along with irritative voiding symptoms -Hematuria

What are the priority nursing actions for urolithiasis?

-Administer analgesics such as hydromorphone (Dilaudid) or morphine sulfate (morphine) as ordered -Administer antiemetics as ordered -Administer alpha blockers as ordered -Maintain fluid status; encourage PO fluids or administer fluids IV as ordered. -Strain urine -Insert Foley catheter if the patient is unable to void

What is the minimum urine outpout?

-Minimal urine output should be between 30 and 50 mL/hr -Decreased urine output may indicate dehydration or an obstructed kidney

What is a cystoscopy?

-Surgical procedure utilized to diagnose and/or treat bladder problems -A cystoscope is a tubular, lighted device that is inserted through the urethra while the patient is sedated and in the lithotomy position -Used to assess for bladder trauma, urethral trauma, or urinary tract obstructions

What preprocedure teaching do you need to provide to a client who is undergoing a cystoscopy?

-Indication of the study and its potential risks -Bowel preparation that should occur the evening prior to the cystoscopy -The need to remain NPO after midnight

What postprocedure teaching do you need to provide to a client following a cystoscopy?

-Expected findings include urinary frequency and pink-tinged urine -Gross bleeding and/or clots in the urine are not normal and should be reported to the healthcare provider

What kind of diet should a client with renal calculi follow?

-Hydration -Low-sodium diet -Increase dietary intake of citrate: Found in lemons and lemonade -Decrease dietary intake of oxalate: Rhubarb, chocolate, tea, coffee, and nuts