Acute Kidney Injury
Abnormal labs expected with AKI
GFR, BUN, Cr, potassium
BUN, Cr, and potassium would be elevated
GFR would be declining
When caring for a burn patient who had an injury less than 48 hours ago, some of the lab values the nurse should share with the dietician include
What are low sodium, low albumin, low total protein?
Your patient had a stroke, prior to allowing them to eat you know we have to make sure they are safe to swallow. There are two cranial nerves we typically assess
What are glossopharyngeal and vagus nerve?
some abnormalities would be the soft palate and tonsillar pillars do not move
The nurse notices a paraplegic patient is sweating profusely, has an elevated blood pressure, bradycardia, urinary retention (full bladder), and fecal impaction. The nurse suspects the patient is experiencing
What is autonomic hyperreflexia?
Osteoporosis is associated with
What is thin and weakened bones?
Clinical manifestations of AKI are
What are decreased urinary output, crackles in bilateral lungs, tachycardia, dyspnea at rest, new-onset generalized edema, confusion?
Some assessment findings that are indicative that the goals of the emergent phase of burn care have been met
What are Map greater than 65 mmHg, heart rate 95 beats /min, airway remains patent?
Your patient is diagnosed with a CVA. Important assessments include
What are neuro exam, HEENT exam, BP and HR?
Spinal cord injuries that sever the spinal cord result in paralysis below the level of injury. The patient has an injury at C4 the nurse performs an assessment and expects to find...
What is a loss of function below the neck and down?
An elderly patient presents after a fall, the nurse identifies several assessment findings consistent with a hip fracture.
What are: the patient describes hearing a "loud pop" sound at the time of the fall, the leg is shortened, and the patient complains of severe pain?
If the patient's AKI worsens; the nurse expects the provider to order
what is hemodialysis, specifically CRRT?
The preferred chart to measure the extent of burns in children
What is the lund browder chart?
know how to calculate this percentage.
You notice your patient is in afib, you know this is a risk factor for ischemic stroke. You notice your patient develops stroke like symptoms. You notify a provider and expect to do the following steps
What is obtain a head CT and administer alteplase if they are a candidate for it?
The client experiences a complete severance at T8. The nurse understands this means complete SENSORY and MOTOR loss of ...
What are both legs, lower trunk, hips, perineum, bowel, and bladder control, and sexual dysfunction?
The client's age, history of osteoporosis, and history of glaucoma are considered
What are risk factors leading to a fall and subsequent hip fracture?
One cause of AKI can be hydronephrosis caused by kidney stones. Findings consistent with urinary stones include
What are urine culture, urinary output, complete blood count, basic metabolic panel, X-ray of kidney, ureter, and bladder, computed tomography of abdomen?
what are daily weights and albumin levels
Before you administer alteplase, a fibrinolytic, you know certain steps must be completed such as
What are: obtain PIV access, administer labetalol if BP is outside of the policy parameters, attach a continuous cardiac monitor, and initiate aspiration precautions?
What are
1. provide O2
2. maintain head in midline neutral position
3. minimize suctioning
4. address monitor alarms immediately
5. monitor for HAs and behavior changes
6. avoid hip flexion (which causes intrathoracic pressure
7. maintain a quiet dimly lit environment
Smore serious complications associated with hip fractures includes
What are neurovascular compromise and urinary retention?
Another cause of AKI can occur as a result of hypovolemic shock. Findings consistent with an improvement in AKI include
What are heart rate in normal range, improvement of urine output, pulse strength improvement, blood pressure in normal range, hgb/hct stabilize?
A patient sustains severe burns, we know fluid resuscitation is a priority. The nurse expects the doctor to order
What is normal saline or lactated ringers?
The nurse knows to monitor for complications of alteplase administration
What are intracerebral hemorrhage and bleeding at puncture sites?
The nurse uses an assessment scale to assess the patient's risk for pressure injuries. This scale measures sensory perception, moisture, activity, mobility, nutrition, friction and shear.
Double Jeopardy.... What is the Braden scale?
When conducting a neurovascular assessment the nurse knows the following are priorities
What is palpate pedal pulses, assess capillary refill, ask the patient to dorsiflex and plantarflex, assess the pain level, ask about numbness or tingling?