Renal-med surg

• 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

135-145 mEq/L

• Hypernatremia: fever, restless, increased fluid retention and increased BP, decreased UO
• Hyponatremia: irritability, confusion, tachycardia, weight loss, seizure, n/v, weakness, anorexia

3.5-5 mEq/L

• Hyperkalemia: muscle cramps in lower extremities with weakness, arrhythmia, lethargy
• Hypokalemia: fatigue, weakness, leg cramps, polyuria, bradycardia

Blood Urea Nitrogen- measures protein breakdown in the liver

Normal Range: 5-25 mg/dL

• Decreased BUN: decreased protein diet, malnutrition, over hydration
• Increased BUN: dehydration, renal disease, UTI, CF, GI bleeding, increased protein intake

• Creatinine: product of muscle of protein breakdown
• Normal range: 05-1.5 mg/dL

• 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

• 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

• Anuria: less than 50mL/day urine output
• Oliguria: less than 500mL/day urine output

• 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

200-800 mOsm/kg

Culture & Sensitivity: checks white cells (5,000-10,000) for infection

Diagnostic imaging of the kidney, ureters & bladder to check structures, stones, foreign bodies, abscesses, tumors or cysts

• 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

• 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

• Catheter inserted into the bladder with dye
• x-rays taken as patient voids
• force fluids after procedure

• 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

• Inflammation and infection of the bladder
• s/s include dysuria, frequency, cloudy urine, urgency
• Treatment is antibiotics both inside and outside of the hospital

• 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

• 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)

• 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

• Dysuria, frequent urination, visible blood or cloudy urine
• Non-localized abdominal discomfort
• Fatigue
• Change in cognitive function
• Less likely to experience fever

• 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

• 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)

• 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

• Stress Incontinence
• Urge Incontinence
• Functional Incontinence
• Iatrogenic Incontinence
• Mixed Incontinence

• Anatomic factors (shorter female urethra)
• UTI
• Foreign bodies (cathers, uretetal stent)
• Functional disorders
• Constipation or voiding disorder
• UTC
• DM or HIV infection

• 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

• 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

• 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

• 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

• Causes: penetrating wound, pelvic fracture, sexual assault
• Treatment: surgery, counseling if applicable

Diabetes and HTN

Daily weights & I/O

**1 kg wt gain=1000 mL fluid retention

• Prerenal
• Intrarenal
• Postrenal

• 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

• 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

• Water is pulled into renal filtrate because of a higher concentration of urea (osmosis)
• Fluid is lost at rapid rate

• 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

• 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)

• 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

• Develops slowly over months or years, may go undetected until GFR >10mL/min
• Progressive, irreversible damage to kidneys and nephrons

• 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)

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

• 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

• 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.

• 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

• 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

• 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