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What is the primary function of the renal system?
- homeostasis
- regulation fluid & electrolytes
- removal of waste
- promote hormones for rbc production, bone metabolism and HTN
- urine production
- regulation of acid-base balance
- activation of vitamin D
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What is the normal range of sodium?
135-145 mEq/L
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What are the s/s of hypernatremia? What are the s/s of hyponatremia?
- Hypernatremia: fever, restless, increased fluid retention and increased BP, decreased UO
- Hyponatremia: irritability, confusion, tachycardia, weight loss, seizure, n/v, weakness, anorexia
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What is the normal range of Potassium?
3.5-5 mEq/L
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What are the s/s of hyperkalemia? What are the s/s of hypokalemia?
- Hyperkalemia: muscle cramps in lower extremities with weakness, arrhythmia, lethargy
- Hypokalemia: fatigue, weakness, leg cramps, polyuria, bradycardia
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What is BUN? What is it's normal range?
Blood Urea Nitrogen- measures protein breakdown in the liver
Normal Range: 5-25 mg/dL
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What are indications of an increased BUN? What are the indications of a decreased BUN?
- Decreased BUN: decreased protein diet, malnutrition, over hydration
- Increased BUN: dehydration, renal disease, UTI, CF, GI bleeding, increased protein intake
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What is creatinine and what is its normal range?
- Creatinine: product of muscle of protein breakdown
- Normal range: 05-1.5 mg/dL
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What are the indications for an increased creatinine? What are the indications for a decreased creatinine?
- Increased Creatinine: renal disease
- Decreased Creatinine: muscle atrophy, aging, may indicate liver disease or low protein intake
* if BUN increases by creatinine does not, dehydration may be the culprit. If BUN and creatinine rise together, it is definitely renal disease
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What are some normal effects of aging on the renal system?
- Decrease in kidney mass, blood glow, gfr, decrease in drug clearance (meds need to be modified to prevent nephrotoxicity)
- Reduced bladder elasticity, muscle tone, capacity
- Increase post void residual, nocturnal urine production
- In females, decrease and thinning of vaginal muscle leading to incontinence and irritation
- In males, BPH
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What is the difference between anuria and oliguria?
- Anuria: less than 50mL/day urine output
- Oliguria: less than 500mL/day urine output
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How much urine is used for a urinalysis? What are the normal values?
- 10mL used for urinalysis
- Color: yellow (shade lends to concentration)
- Odor: no foul odor
- Protein: 0-18
- Glucose: none
- Bilirubin: none
- Ketones: None
- Specific gravity: 1.010-1.030
- RBCs:0-4
- WBCs:0-5
- Leukocyte esterase: none
- Nitrates: none
- crystals & casts: limited
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What is the normal urine osmolarity?
200-800 mOsm/kg
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What is a C&S?
Culture & Sensitivity: checks white cells (5,000-10,000) for infection
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What is a KUB?
Diagnostic imaging of the kidney, ureters & bladder to check structures, stones, foreign bodies, abscesses, tumors or cysts
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What is an Intravenous Pyelogram (IVP) or excretory urogram?
- Intravenous contrast or radiopaque dye is circulated (check for allergy to iodine or shellfish!) in blood and then excreted by kidneys into urine
- Evaluates the presence, position, size & shape of structures
- Detect cysts, tumors, lesions or obstruction
- Patient may feel warm or taste salt
- *Contract medium can be nephrotoxic, do not use in decreased renal function
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What is a nuclear kidney scan?
- Radioisotopic dye is monitored in the blood stream as it goes through the kidneys
- After exam, force fluid to excrete dye
- Captopril may be given at start of procedure to change blood flow
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What is a cystography or urethrography?
- Catheter inserted into the bladder with dye
- x-rays taken as patient voids
- force fluids after procedure
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What is a pyelogram?
- Inspects the interior of the bladder with a scope
- Ureteral catheters inserted into the renal pelvis
- Saline solution used to distend the bladder
- Used to inspect interior of bladder, obtain urine sample from kidney, visualize renal structure, biopsy growths, remove small tumors, dilate ureter
- Local anesthetic is used. Teach patient relaxation and deep breathing
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What is cystitis?
- Inflammation and infection of the bladder
- s/s include dysuria, frequency, cloudy urine, urgency
- Treatment is antibiotics both inside and outside of the hospital
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What is interstitial cystitis?
- Chronic, painful inflammatory disease often mistaken for a UTI
- May be provoked by an infection or an autoimmune disease
- Lining of the bladder is destroyed causing irritation by urine
- Moderate to severe pain, relieved by urination
- Will get better and worse over time
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What are some predisposing factors for a UTI?
- Nosocmial infection (catherization)
- Sexual Intercourse
- Bacteria from vagina or rectum
- Factors increasing urinary stasis (including medications leading to urinary retention)
- Intrinsic obstruction (stone, tumor)
- Extrinsic obstruction (tumor, fibrosis)
- Urinary retention (neurogenic bladder)
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What are some natural defenses against UTIs?
- Normal voiding and complete bladder emptying
- Normal antibacterial ability of bladder & urine
- Ureterovesical junction competence
- Peristaltic activity that propels urine to bladder
*alteration in any of these increases the risk of UTI
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What are some s/s of UTI in the older adult?
- Dysuria, frequent urination, visible blood or cloudy urine
- Non-localized abdominal discomfort
- Fatigue
- Change in cognitive function
- Less likely to experience fever
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What can you teach the client with a UTI?
- Take your antibiotics for the full course even if you feel better
- Practice good perineal hygiene
- Empty bladder before and after intercourse (drink fluids)
- Empty bladder every 2-4hrs
- Drink 8 glasses of fluids/day
- Avoid caffeine and other irritating foods, soaps, powders & sprays
- Contact PCP if s/s persist after completing medication
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What are some nursing interventions for a UTI?
- Force fluids
- Avoid irritants such as alcohol, coffee, tea, citrus, spices, colas, alcohol
- Frequent voiding (I/O)
- Patient education (cranberry juice or 1000mg vitamin C)
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What is urethritis? How is it treated?
- Urethritis: inflammation of the urethra
- Caused by bacteria, virus, irritans, STDs
- Treatment is based on cause and treatment relief
- Avoid sexual intercourse until symptoms subside
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What are the different types of incontinence?
- Stress Incontinence
- Urge Incontinence
- Functional Incontinence
- Iatrogenic Incontinence
- Mixed Incontinence
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What are the predisposing factors for incontinence?
- Anatomic factors (shorter female urethra)
- UTI
- Foreign bodies (cathers, uretetal stent)
- Functional disorders
- Constipation or voiding disorder
- UTC
- DM or HIV infection
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What are some treatment options for incontinence?
- Kegal exercises to strenghthen muscles
- Crede method to promote bladder emptying
- Toileting schedule/journal
- Medications: anticholinergic agents, tricuclic antidepressants (inhibit bladder contraction), sudafed (urinary retention), hormone therapy
- Surgery
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What are common sites for urinary tract calculi? What are the s/s?
- Common sites: ureteropelvic junction (UPJ) add Ureterovrsical Junction (UJV
- S/S include: flank pain (Severe), abdominal pain, heamturia, dysuria, n/v, fever, cool moist skin
*obstruction may cause hydronephrosis
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What are the risk factors for UTC?
- Metabolic/diet
- Genetic Factors/family history of stones or gout
- Abnormalities resulting in increase urine levels of calcium, uric acid or citric acid
- Large intake of protein or calcium
- Warm climates cause more fluid loss/dehydration
- Low fluid intake
- Sedentary lifestyle or immobility
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What are some treatment options for UTC?
- Stent may be placed to prevent the buildup of sand
- Increase fluids
- Endoscopic procedures (often with cystoscope) to remove stone
- Lithotripsy-ultrasonic waves, laser, or water bath to break up stones to be urinated out
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What are some causes of bladder trauma? What are some treatments?
- Causes: penetrating wound, pelvic fracture, sexual assault
- Treatment: surgery, counseling if applicable
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Describe a Urinary diversion
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Describe an orthotopic bladder substitution
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What are the two forms of polycystic kidney disease? What are the s/s and diagnosis?
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What are some treatments for obstructive disorders?
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What is Pyelonephritis? What are the s/s?
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What is the cause of acute glomerulonephritis? How is it treated?
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What is chronic glomerulonephritis? How is it treated?
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What is nephrotic syndrome?
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How is nephrotic syndrome managed?
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What are some renal degenerative changes?
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What are the two leading causes of chronic kidney failure?
Diabetes and HTN
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What is diabetic neuropathy?
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What is the definition of renal failure?
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What is the best indicator of fluid retention or fluid loss?
Daily weights & I/O
**1 kg wt gain=1000 mL fluid retention
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What are the characteristics of Acute Kidney Injury?
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What are the three categories of AKI?
- Prerenal
- Intrarenal
- Postrenal
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What are the 4 phases of AKI?
- 1. Initiating
- 2. Oliguric
- 3. Diuretic
- 4. Recovery
*prerenal and postrenal resolve quickly if cause is found, intrarenal may be prolonged or lead to CRF
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What is the oliguric phase of AKI?
- Hyponatremia, Hyperkalemia, Anemia
- Abnormalities in PLTs & altered WBCs
- Decreased UO, fluid retention
- Output less than 400 mL/day
- Increased BUN & creatinine
- Kussmaul's resps, lethargy
- Seixures, stupor, coma, fatigue, difficult concentrating
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What is the Diuretic phase of AKI?
- Water is pulled into renal filtrate because of a higher concentration of urea (osmosis)
- Fluid is lost at rapid rate
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What is the Recovery phase of AKI?
- Begins when the GFR increases, major improvements seen in 1-2 wks but can take up to a year for renal function to stabilize
- BUN/Creatinine levels platwu and then decrease
- Older adults are less likely to recover and lead to CKD
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What are some medications used for treatment of AKI?
- Lasix or Bumex (loop diuretic)
- Hydrochlorothiazide (thiazide diuretic)
- Mannitol (osmotic diuretic)
- Phoslo (calcium salts, mineral and electrolyte replacements, binds to and eliminates phosphorus)
- Renegal (electrolyte modifier, binds to and eliminates phosphorus)
- Kayexalate (electrolyte modifier, binds to and eliminates potassium. May be given as an enema)
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Describe a renal health diet
- Protein restriction-may be adjusted for dialysis
- Potassium restriction- needed to prevent hyperkalemia
- Phosphate restriction-along with potassium
- Sodium restriction- to manage fluid retention, HTN
* reduce production of waste that kidneys cannot excrete, including excess of electrolytes. Correct any deficiencies
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What is chronic kidney disease?
- Develops slowly over months or years, may go undetected until GFR >10mL/min
- Progressive, irreversible damage to kidneys and nephrons
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What are the 5 stages of kidney failure?
- Based on GFR, normal rate is 120mL/min
- Stage 1: GFR > or = 90 mL/min
- Stage 2: GFR 60-89 mL/min
- Stage 3: GFR: 30-59 mL/min (moderate damage)
- Stage 4: GFR 15-29 mL/min (severe)
- Stage 5: <15 mL/min (in need of dialysis or transplant) (also called End Stage Renal Disease, when 90% of nephrons are lost)
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How does chronic kidney disease effect electrolyte imbalance? What about acid-base balance?
As kidneys lose the ability to excrete electrolytes, hyperkalemia, hyperphosphatemia (>5mg/DL), hypermagnesia & hypernatremia result
Hypocalcemia (<8.5mg/dL)results as kidneys are unable to activate vitamin D needed for calclium absorption. Bones suffer from osteoporosis as they try to make up for the deficit
Acid-Base balance is disturbed as the kidneys cannot excrete hydrogen ions, leading to metabolic acidosis. Body tries to compensate by kussmaul resps
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What are some s/s of kidney failure?
- Electrolyte imbalances
- Increase in BUN & creatinine as wastes are not being excreted
- Disturbances in acid-base balance
- lethargy, fatigue, confusion, n/v, seizures, arrhythmias, anorexia, stupor,coma
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Describe hemodialysis
- Artificial kidney is used outside of the body to remove excess water and waste
- Patient hooked up to machine with artificial kidney by catheter or access port
- Dialysate is hypertonic and pulls waste and extra water from blood
- Rapidly removes waste, may cause fatigue, weakness, decrease in electrolytes, cardiac arrhythmias and hypotension
- Takes 2-4 hrs, 3-4 times/wk
- Occurs at hospital or hemodialysis center
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What are the types of access for hemodialysis?
- Arteriovenous Graft: piece of special graft materal sewn to an artery and then attached to a vein
- Arteriovenous fistula: made by sewing the artery and vein together (anastomosis)
artery is accessed, blood goes through kidney, returned through access in vein.
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Describe peritoneal dialysis
- catheter is placed in peritoneal cavity
- dialysate is filled by gravity into peritoneal cavity (about 2L dialysate)
- capillaries in peritoneal cavity allow for exchange of water and waste with hypertonic dialysate as it dwells
- Dialysate is drained from peritoneal cavity by gravity after a prescribed amount of time (2-4hrs)
- Automated peritoneal dialysis is done by a machine and is most likely done at night while the patient is sleeping
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What are nursing interventions for Renal Failure?
- Monitor weights
- I/O and pulmonary assessment may be done hourly
- Monitor for pulmonary and peripheral edema
- Provide comfort measures (Esp for uremia/uremic frost)
- Bed rest to reduce metabolic rate
- Prevent fever and infections
- Provide psychosocial support
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How is CKD medically managed?
- Treated symptomatically
- Dialysis
- Renal Diet
- Management of HTN & DM
- Drug therapy for electrolyte imbalances
- Epogen or Procrit for anemia
- --most drugs are excreted through the kidneys, there is a higher risk of toxicity
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