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Critical Care Exam 3


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What are the most common causes of acute renal failure?
hypotension and prerenal hypovolemia
What are the prerenal causes of ARF?
circulatory volume depletion, volume shifts, decreased cardiac output, decreased peripheral vascular resistance, vascular obstruction
What are the intrarenal causes of ARF?
kidney disease, acute tubular necrosis
What are the postrenal causes of ARF?
obstruction of the urinary tract within the tubules or the ureter or the urethra
What are the 4 phases of ARF?
1. Onset phase 2. Oliguric-anuric or nonoliguric phase 3. Diuretic phase 4. Recovery phase
When does the onset phase occur and how long does it last?
From the precipitating event to the development of renal manifestations and may last minutes, hours, or a week.
How long does the oliguric-anuric or nonoliguric phase last and what treatment does it require?
1 to 8 weeks and may require dialysis
What are the characteristics of the diuretic phase?
gradual or abrupt return to glomerular filtration and leveling of BUN... urine output may be 1000-2000 ml/day and may lead to dehydration
How long does the recovery phase last and what are its long-term effects?
3 to 12 months... mild tubular abnormalities may continue for years putting the client at continual risk of fluid and electrolyte imbalance, especially during times of stress.
What are the symptoms of non-oliguric renal failure?
Up to 2 L/day of dilute and nearly isomolar urine, low urine specific gravity, hypertension, tachypnea with symptoms of fluid overload, symptoms of fluid depletion such as dry mucous membranes, poor skin turgor, and orthostatic hypotension.
What are the medical managements of ARF?
maintenance of fluid and electrolyte balance and nutrition, fluid replacement, administration of diuretics, electrolyte replacement, high calorie-low protein diet
What is the nurse's role in the medical management of ARF?
Assess fluid status carefully. Meticulous skin care. Avoid catheters and watch for symptoms of infection. Pulmonary hygiene. Prevention of anemia. Frequent careful explanations to relieve anxiety. Teaching about disease and implications.
What is peritoneal dialysis?
The introduction of sterile dialyzing fluid into the peritoneal cavity to draw out extra fluid and solutes, and then the drainage of that fluid by gravity.
What is hemodialysis?
Blood is diverted from the client through a pump from the client's artery. The toxins are diffused across a semipermeable membrane into the dialysate and the blood is returned to the client's body via a vein.
What are some possible complications of dialysis?
technical problems, hypotension, hypertension, cardiac arrhythmias from potassium imbalance, air embolus, hemorrhage from heparinization, GI bleeding, infection, and dialysis equilibrium syndrome
What is dialysis equilibrium syndrome?
Occurs due to rapid removal of some ions from the blood. Symptoms: mental confusion, deterioration of the LOC, headache, and seizures.
Which type of kidney transplant has better survival rates?
Living donor transplants
What are the only absolute contraindications to transplantation?
Infection and active malignancy
What are the legal guidelines for cadaver donors?
Must be declared brain dead, under 60 years of age, have normal renal function, no malignant disease outside the CNS, no generalized infection, no significant hypertension, no abdominal or renal trauma, negative hepatitis B antigen and HIV antibody and continuous ventilation and heartbeat until kidneys are surgically removed.
How must kidneys be preserved before a transplant?
Warm and ischemic for 1 hour. Cool and ischemic for 24 to 48 hours.
What are some complications of kidney transplants?
Graft rejection, immunosuppressive therapy consequences, infection, spontaneous rupture of kidney, hypertension, Hep B, cirrhosis, peptic ulcer, slow wound healing, MI, stroke, heart failure
What are the symptoms of renal cancer?
hematuria, flank pain, palpable abdominal or flank mass, fever, weight loss, fatigue, hypertension, amyloidosis, thrombophlebitis, anemia, erythrocytosis, hypercalcemia, abnormal serum liver profile, elevated sed rate
What are some nursing interventions for the nephrectomy patient?
reestablish effective breathing pattern, pain relief, monitor urinary output, begin oral intake only after adequate bowel function is reestablished, keep family informed
What is plasmapheresis?
Plasma exchange
What is the order of assessment for the GI system?
Inspection, Auscultation, Percussion, Palpation
How long do you listen when auscultating the GI system?
5 to 15 seconds
What do you watch for when the GI system is obstructed?
peritonitis and hypokalemia
Why do people get esophagogastric varices?
Portal hypertension causes an increase in portal blood flow. Blood is diverted to the thin-walled vessels of the esophagus and proximal stomach causing them to become engorged and dilated.
What is the treatment for varices?
What are nursing interventions for a CT scan?
If contrast is used, check for iodine allergy before study. Monitor for allergic reaction after procedure. Ensure hydration after procedure.
How is liver failure definitively diagnosed?
elevated serum bilirubin, aspartate transferase (AST), alkaline phosphatase, serum ammonia, and decreased serum albumin
What do you do for a person with GI hemorrhage?
Begin fluid replacement first then stop the bleeding.
What are the signs and symptoms of Stage I hepatic encephalopathy?
euphoria or depression, mild confusion,slurred speech, disordered sleep rhythm, slight asterixis and normal EEG
What are the signs and symptoms of Stage II hepatic encephalopathy?
lethargy, moderate confusion, marked asterixis and abnormal EEG
What are the signs and symptoms of Stage III hepatic encephalopathy?
marked confusion, incoherent speech,sleeping but arousable, asterixis present and abnormal EEG
What are the signs and symptoms of Stage IV hepatic encephalopathy?
coma, initially responsive to noxious stimuli, later unresponsive, asterixis absent and abnormal EEG
What do you look for in the patient with GI hemorrhage?
hypovolemic shock
What is the number one cause of GI hemorrhage?
peptic ulcer
What are some possible complications following an endoscopy?
hemorrhage, perforation, aspiration due to absence of gag reflex
What are some problems that accompany liver failure?
encephalopathy, confusion
What lab value is most indicative of acute pancreatitis?
serum lipase
What causes acute pancreatitis?
gallstones and alcoholism
What is the patient with acute pancreatitis at risk for?
hypovolemic shock, acute respiratory distress syndrome, acute respiratory failure, and GI hemorrhage
What are the signs and symptoms of liver failure?
headache, hyperventilation, jaundice, personality changes, palmar erythema, spider nevi, bruises, and edema
When do you do continuous renal replacement therapy?
ONLY if the patient is in renal failure
What are the stages of shock?
initial stage, compensatory stage, progressive stage, refractory stage
What are the signs and symptoms of shock?
SBP < 90 mmHg with tachycardia (or bradycardia if neurogenic) and altered mental status
What is the first sign of neural involvement with shock?
decreased level of consciousness
What does adequate tissue perfusion depend on?
supply of oxygen to the tissues and the cells ability to use oxygen
Why do you give albumin for third spacing?
to pull fluid from the interstitial spaces
What do you give first for third spacing?
albumin then Lasix
What is the number one sign of hypovolemic shock?
decreased blood pressure... the patient will feel dizzy
What are the nursing interventions for hypovolemic shock?
Give fluids with crystalloids and colloids. Prevent shock by identifying patients at high risk. Monitor intake and output. Daily weights (no more than 2 pound decrease). Assess for sacral edema and ascites. Minimize fluid loss. Minimize blood sampling by consolidating labs. Watch lines for disconnections. Use the largest bore catheter reasonable.
What is the most common cause of neurogenic shock?
spinal cord injury above the level of the sixth thoracic vertebra
What med is given for ineffective airway with cardiogenic shock?
What is the most important therapy goal with all types of shock?
treat or remove the cause
How is neurogenic shock bradycardia treated?
Who is at risk for septic shock?
anyone with an infection
What is the goal for pulmonary artery wedge pressure?
15-18 mm Hg
Why are trauma patients especially at risk for multiple organ dysfunction syndrome?
often have prolonged periods of circulatory shock with tissue hypoxemia, tissue injury, and infection
What types of patients are at high risk for MODS?
ruptured aneurysm, acute pancreatitis, sepsis, burns, surgical complications, 65 years or older
What is primary MODS?
a condition directly causes MODS
What is secondary MODS?
MODS from an indirect cause due to widespread systemic inflammation
What are the possible outcomes of primary MODS?
recovery, stable metabolic state, or death
What is the most common complication of SIRS and MODS?
acute respiratory distress syndrome
What are the goals for medical management of MODS?
prevention of infection, treatment of infection, maintain tissue oxygenation, nutritional/metabolic support, support for individual organs

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