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A comprehensive overview of urinary tract infections (utis), acute kidney injury (aki), and chronic kidney disease (ckd). It covers key aspects such as diagnosis, treatment, and management of these conditions. Detailed information on common pathogens, risk factors, clinical manifestations, diagnostic tests, and treatment options for utis. It also explores the causes, classification, and management of aki, including prerenal, intrarenal, and postrenal failure. Additionally, the document discusses the stages of ckd, drug dosage modifications based on kidney function, and the management of complications associated with aki and ckd. Valuable for students and professionals in the field of nursing and medicine.
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Urine culture with UTI (ANS- 100.000 colonies in asymptomatic: bacteruria 10 - 10.000 colonies in symptomatic patients but also pyuria pyuria: more than 10 leukocytes elevated erythrocytes with pyelonephritis WBC in urine false positive with tumor, urethritis and poor collection technique Repeat in pregnant women Lower urinary tract UTI and upper urinary tract UTI (ANS- bladder and urethra: cystitis/ urethritis/ prostatitis kidney and ureters: pyelonephritis/ renal abcess Uncomplicated and complicated uti (ANS- Uncomplicated: in normal working urinary tract Complicated: defects in urinary tract or with other health problems Common pathogens for UTI (ANS- E.coli (elderly women) Staphylococcus proteus mirabilis (elderly men)
Klebsiella enterecoccus pseudomonas Providencia (institutionalized) Fungus: candida
Risk factors for UTI (ANS- Female critically ill elderly catheter (caused by biofilm) DM calculi, tumor, stricture neurogenic bladder Women: sexual intercourse or new sex partner pregnancy previous UTI Men: prostate enlargement prostatitis lack of circumcision gay HIV Findings UTI (ANS- Lower: Dysuria/ urgency/ frequency/ incontinence suprapubic pain hematuria fever/ chills uncommon No flank pain Upper: flank pain fever and chills hematuria n/v ams (in elderly)
malaise tachycardia/ tachypnea Testing and results for UTI (ANS- Gold standard: urine culture and sensitivity: detection of bacteria. Start with POC: urine analysis. UA: pos for nitrite or leukocyte or blood CBC: leukocyte with left shift in pyelonephritis For recurrent UTI in women or UTI in men rule out obstruction, calculi, or necrosis with: xr voiding CT abdomen US pelvis MRI pelvis Management acute cystitis (ANS- First line:
Ceftriaxone or cefotaxime Ampicillin CAUTION: bacterial: treat with AB for 7 days Candiduria: fluconazole for 14 days Discomfort: Pyridium Management acute complicated bacterial pyelonephritis (ANS-
Sediment: + BUN/ creat ratio: less than 20/ FEna: greater than 2% Treat: stop offending drug. Contrast: fluid administration, pre- and post. Hold metformin before contrast, for 48hrs. Postrenal (ANS- Cause: Urinary flow obstruction: Enlarged prostate Cervical cancer Tumors Kidney stones Neurogenic bladder, diabetic neuropathy, spinal cord disease
o Prevent complications o Lasix can be given for volume overload (due to oliguria) o Patient can become nutritionally deficient as ARF is a catabolic state. Total caloric intake: 30 - 45 kcal/kg/day. Protein restricted when not on dialysis: 0.6g/ kg/day. If on dialysis protein should be 1-1.5g/kg/day. Diet should be low protein/ Na/ K o Dialysis, often needed. Especially when BUN greater than 100 and serum creatinine greater than 5 - 10, acidosis/ alkalosis, hyperkalemia o Metabolic acidosis: treat with IV (or oral) bicarb when serum HCO3 is less than 15, or PH less than 7. o Renal transplant Treat renal failure complications: which and how (ANS- Hyperkalemia:
Fluid overload:
o When GFR between 5 - 10: dialysis o Creatinine clearance: age and gender-dependent. Males: 97-137, Females: 88- 128 o Signs/ Symptoms:
(ANS- abnormal excretion rates abnormal metabolism rates abnormal sensitivity to drugs benign prostatic hyperplasia (ANS- enlargement of prostate gland in men older than 50yrs, interfering with urinary flow by obstructing the urethra (straining, frequency, dribbling, incontinence, nocturia) Diagnosis of bph: definition and symptoms (ANS- Prostate enlargement during digital rectal exam (if nodules or hardness is felt than concern for malignancy)
renal artery stenosis (ANS- Renal artery stenosis causes ischemia in artery providing the affected kidney with blood. In turn the kidney will produce renin which causes HTN. Kidney will also shrink (atrophy): ischemic nephropathy. Long term it can lead to chronic RF. Renal artery stenosis: signs, tests, management (ANS- · Signs: sudden or unexpected HTN epigastric bruits edema increase/ decrease urine itching dry skin n/v muscle cramping unexplained hf/ pulm edema decline in gfr metabolic acidosis · Tests: doppler/ ultrasound and CT-angio of renal arteries (risk of contrast induced nephropathy) · Management: o Life-style changes o Meds to optimize glycemic control, blood pressure, cholesterol o ACE-inhibitors (Pril), ARB's (tan) (further decline in GFR may occur) o RAAS-blockade (ACE and ARB), statin, aspirin: cornerstone therapy o Check kidney function after two weeks of starting ACE and ARB: may cause acute RF. o Diuretic, beta-blocker, or calcium channel blocker might be needed as well
nephrolithiasis: definition, risk factors (ANS- - stones in pelvis, kidney or ureter
Diagnostic criteria for DM (ANS- o Random glucose greater than 200mg/ dl o Two hour post glucose test greater than 200 mg/dl o HgbA1C greater than 6.5% (measure every 6mo post diagnosis; less than 6% is goal. Measure q3 - 4mo when using sliding scale) o Fasting glucose greater than 126 mg/dl on two occasions o Urine will show glycosuria and ketonuria Standard insulin dose for new diabetic type 1 (ANS- - 0.5units/ kg/ day, 2/3 in the morning and remaining 1/3 in evening (regular)
· Hydration: NS at 1000ml/hr for 1-2 hrs, then 300-500ml/hr for 4 hrs to correct deficit of 4-8ltr. Then 250ml/ hr. First isotonic, then hypotonic. Change to D 0.45NS once glucose lower than 250 mg/dl. Add K if potassium smaller than 5 to first bags of fluid. · Monitor K, phos, mag · Loading dose insulin: 0.1 units/ kg regular insulin followed by continuous drip of 0.1units/kg/hr. Decrease to 0.05units/kg/hr once glucose less than 200mg/ dl · If PH less than 7.0. give Bicarb (50 -100 mEq in 1 ltr fluid). DC bicarb when PH
Management DM (ANS- - Diet: carb 60% of total intake, fats 25% of total, protein 15% of total. Artificial sweetener better than sugar. Balance and individualized. DM1: 3 meals/ day + 3 snacks. DM2: meals 5 hours apart, no snacks.
Dawn phenomenon (ANS- Early morning glucose elevation because of growth hormone which decreases sensitivity to insulin. Add/ increase bedtime dose of insulin Oral Antidiabetic Drugs (ANS- 1. Biguanides (Metformin)
§ Action: reduces insulin resistance and may decrease glucose production § Adverse effect: upper resp infection, sinusitis, fluid retention and thus heart failure. Do not give for HF patients! Ovulation, bladder cancer, fractures (in women) Alpha-glucosidase ihibitors (ANS- acarbose, miglitol § Action: delay absorption of carbs § Adverse effects: cramping, flatulence, abd distention Take with first bite of meal not with garlic, juniper, ginseng Dipeptidyl Peptidase-4 Inhibitors: (ANS- Linagliptin, Saxagliptin § Action: enhances incretin hormones § Use: add-on to metformin contraindicated for ESRD Sodium-glucose cotransporter 2 inhibitors (ANS- Canagliflozins § Action: blocks glucose reabsorption in kidneys. § Adverse effects: vaginal fungal infections/ vulvovaginitis, genital infections (increased sugar in urine). DKA: definition and signs (ANS- Intracellular dehydration due to hyperglycemia, hyperketonemia, acidotic PH N/V, weakness, AMS, tachycardia, fruity breath, kusmaul breathing, hyperkalemia, hypotension Glucose greater than 300mg/dl PH less than 7. Ketones in serum and urine Hyperkalemia increased BUN Leukocytosis serum hyperosmolality (greater than 280) Increased anion gap
HHS: definition and signs (ANS- Severe hyperglycemia, hyperosmolality without ketone production, often DM 2 Weakness, AMS, hypotension, tachycardia, shallow breathing Glucose greater than 600mg/dl Serum hyperosmolality, greater than 310 increased BUN and creat Hypernatremia PH greater than 7. Normal anion gap Management of HHS (ANS- Critical care Fluid replacement: isotonic fluids, hypotonic once Na+ reaches 145 (4-6ltr in 10hrs) Monitor for fluid overload Loading dose of 0.1-0.15units/ kg of regular insulin followed by drip Monitor and replace electrolytes Hypoglycemia treatment (ANS- In hospital: D50W 25-50ml, Glucagon 1mg, Glucose tab 16gr. Follow with D5W to maintain glucose greater than 100mg/dl Community: Glucose tab 16gr 4oz sweetened carb drink or unsweetened fruit juice or soft drink 1 tbsp honey 5 pieces hard candy Hyperthyroidism: definition, cause, findings, management (ANS- Excess T secretion and T Graves' disease: goiter and ocular changes Subacute thyroiditis TSH pituitary tumor or thyroid ca High dose amiodarone
Hypermetabolism, heat intolerance, nervousness, tremors, diaphoresis, hyperreflexia, tachycardia/ afib, diarrhea, protruded eye T4 may be normal, T3 elevated Hypercalcemia Anemia Propranolol/ metoprolol Antithyroid meds: methimazole Radioactive iodine: destroy goiters Thyroid surgery Thyroid storm: definition, cause, findings, management (ANS- Deadly, hypermetabolic state caused by uncontrolled hyperthyroidism trauma, stress, infection, uncontrolled dm, pregnancy Fever, flushing, produse sweating, tachycardia (SVT), delirium/ psychosis, hyperdefeaction, hyperglycemia Hypothermic measures (Tylenol), avoid aspirin and NSAID (bind with T4) Antithyroid meds: methimazole followed with Lugol's solution Esmolol, hydrocortisone No surgery till euthyroid Hypothyroidism (Myxedema coma): definition, cause, findings, management (ANS- greatly decreased metabolism caused by deficient amount of thyroid hormone Iodine deficiency (most common) Hashimoto's: autoimmune thyroiditis Deficiency of pituitary TSH Thyroidectomy High dose Amio
Fatigue, hypoventilation, bradycardia, hypothermia, hypoglycemia, weight gain, constipation, cold intolerance, parasthesias, Periorbital edema, enlarged tongue, horaseness Elevated TSH, low or normal T4 hyponatrenia anemia hypercholesterolemia Levothyroxine (T4). Younger than 60 without CAD: 50 - 100mcg daily, older than 60 with CAD: 25 - 50mcg daily. Check TSH after 8 wks. Myxedema coma treatment (ANS- Give O2 Fluid restriction and NS 3% for severe hyponatremia D50W for hypoglycemia IV thyroid replacement: levothyroxine. Give hydrocortisone of adrenal insufficiency is suspected. Rewarming with blankets (no warming blankets: rapid vasodilation may cause hypotension) Cushing's syndrome: definition, cause, findings, management (ANS- condition caused by prolonged exposure to high levels of cortisol, commonly because of ACTH secretion Benign pituitary adenoma Adrenal neoplasm Nonpituitary neoplasm, such as small cell lung ca Excessive glucocorticoid administration (syndrome) Central obesity with muscle wasting, moon face, emotional lability, bruising, htn, polyuria, hyperglycemia, osteoporosis Hypokalemia Hypernatremia Leukocytosis Elevated serum cortisol (give dexa at 11pm, check cortisol at 8am, greater than 1.8 is CS)
Elevated free urinary cortisol (24hr urine, greater than 50mcg/24hr is CS) Metabolic alkalosis Hyperglycemia Hypertension Secondary male characteristics Treat underlying cause (tumor resection, dc glucocorticoids) manage fluid and electrolyte imbalance Addison's disease: definition, cause, findings, management (ANS- Condition caused by deficiency of cortisol, androgens, and alsdosterone (adrenal gland is not working) Sudden withdrawal of glucocorticoids sepsis autoimmune destruction of adrenal gland metastatic ca pituitary failure causing decreased levels of ACTH weakness, n/v, abd pain, diarrhea, hyperpigmentation, hypotension Hyponatremia Hyperkalemia Hypoglycemia Neutropenia Plasma cortisol less than 5mg/dl at 8am metabolic acidosis Glucocorticoid and mineralcorticoid replacement therapy: Hydrocortisone and potentially fludrocortisone (decrease dose with htn, edema, hypokalemia) Adrenal crisis: definition, findings, management (ANS- acute adrenocortical insufficiency, often caused by infection Sever weakness, n/v, abd pain, hypotension, fever, tachycardia, ams/ lethargy Hyponatremia
Hyperkalemia Hypoglycemia Neutropenia Plasma cortisol less than 5mg/dl at 8am Metabolic acidosis Obtain cortisol level Give hydrocortisone (Solu-Cortef) 100- 300mg IV, then 50-100mcg q6h, taper after 4 days K replacement Broad spectrum ab's Treat underlying cause Pheochromocytoma: definition, findings, management (ANS- a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine and norepinephrine resulting in sustained HTN Classic triad: palpitations, severe headache, profuse diaphoresis tachycardia, nausea, weakness, HTN, tachy, chest pain, dyspnea Hyperglycemia Leukocytosis urinary catecholamine greater than 135 metanephrine greater than 2.2 (most sensitive) Treat HTN with alpha-blockers (phentolamine) then beta-blocker (propranolol), or nicardipine for HTN crisis SIADH: definition, cause, findings, management (ANS- Condition resulting from secretion of antidiuretic hormone (ADH) resulting in water retention Malignancies CNS disorders Chronic lung diseases certain drugs: antidepressants, NSAIDS
Hyponatremia with symptoms (headache, seizures, somnolence), Hypothermia, concentrated urine and decreased uo, vomiting/ abd cramping, decreased deep tendon reflexes Hyponatremia (less than 120) Decreased serum osmolality increased urine osmolality increased urine Na Decreased BUN Treat underlying cause Restrict water intake If symptomatic: Increase Na by 1-2mEq/hr, but not more than 10-12mEq per 24hr to reach Na 125-130mEq Not symptomatic: Increase Na with NS 0.9% 0.5mEq/L/hrwith 0.5-1mg/kg of lasix for Na lower than 120. Hypertonic 3%NS with or without lasix Na level every 2-4 hrs diabetes insipidus: definition and types (ANS- Polyuric syndrome because antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect Central - deficiency of ADH production, caused by CNS patients, trauma, pituitary tumor, syphilis Nephrogenic - renal insensitivity to ADH, caused by renal disease or meds such as lithium, methicillin Psychogenic Diabetes insipidus: findings and treatment (ANS- Thirst, hypotension, tachycardia, increase uo (2 - 20ltr/ 24hr), low urine specific gravity (less than 1.006) hypernatremia hypokalemia hypercalcemia increased serum osmolality