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What is the primary function of the renal system?
- 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
What is the normal range of sodium?
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
What is the normal range of Potassium?
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
What is BUN? What is it's normal range?
Blood Urea Nitrogen- measures protein breakdown in the liver
Normal Range: 5-25 mg/dL
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
What is creatinine and what is its normal range?
- Creatinine: product of muscle of protein breakdown
- Normal range: 05-1.5 mg/dL
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
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
What is the difference between anuria and oliguria?
- Anuria: less than 50mL/day urine output
- Oliguria: less than 500mL/day urine output
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
- Leukocyte esterase: none
- Nitrates: none
- crystals & casts: limited
What is the normal urine osmolarity?
What is a C&S?
Culture & Sensitivity: checks white cells (5,000-10,000) for infection
What is a KUB?
Diagnostic imaging of the kidney, ureters & bladder to check structures, stones, foreign bodies, abscesses, tumors or cysts
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
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
What is a cystography or urethrography?
- Catheter inserted into the bladder with dye
- x-rays taken as patient voids
- force fluids after procedure
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
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
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
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)
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
What are some s/s of UTI in the older adult?
- Dysuria, frequent urination, visible blood or cloudy urine
- Non-localized abdominal discomfort
- Change in cognitive function
- Less likely to experience fever
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
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)
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
What are the different types of incontinence?
- Stress Incontinence
- Urge Incontinence
- Functional Incontinence
- Iatrogenic Incontinence
- Mixed Incontinence
What are the predisposing factors for incontinence?
- Anatomic factors (shorter female urethra)
- Foreign bodies (cathers, uretetal stent)
- Functional disorders
- Constipation or voiding disorder
- DM or HIV infection
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
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
What are the risk factors for UTC?
- 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
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
What are some causes of bladder trauma? What are some treatments?
- Causes: penetrating wound, pelvic fracture, sexual assault
- Treatment: surgery, counseling if applicable
Describe a Urinary diversion
Describe an orthotopic bladder substitution
What are the two forms of polycystic kidney disease? What are the s/s and diagnosis?
What are some treatments for obstructive disorders?
What is Pyelonephritis? What are the s/s?
What is the cause of acute glomerulonephritis? How is it treated?
What is chronic glomerulonephritis? How is it treated?
What is nephrotic syndrome?
How is nephrotic syndrome managed?
What are some renal degenerative changes?
What are the two leading causes of chronic kidney failure?
Diabetes and HTN
What is diabetic neuropathy?
What is the definition of renal failure?
What is the best indicator of fluid retention or fluid loss?
Daily weights & I/O
**1 kg wt gain=1000 mL fluid retention
What are the characteristics of Acute Kidney Injury?
What are the three categories of AKI?
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
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
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
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
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)
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
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
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)
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
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
- 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
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.
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
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
How is CKD medically managed?
- Treated symptomatically
- 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