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Older Adults Pt 2 > 10.1 Renal > Flashcards

10.1 Renal Flashcards

1
Q

Renal System

A
  • Regulates fluid and electrolytes
  • Removes wastes
  • Provides hormones in RBC production, bone metabolism
  • Controls BP
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2
Q

Normal Bladder

A
  • Capacity of 300-500 mL
  • It is normal to find Urea in Urine
  • Glucose is abnormal to find in Urine
  • Fluid loss is most accurately measured by body weight
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3
Q

Older Adults Kidney Issues

A
  • Older adults are more susceptible to sclerosis of glomerulus, decreased blood flow, decreased GFR, altered tubule function, acid base imbalances.
  • Older adults have incomplete bladder emptying (urinary stasis), and decreased drug clearance leading to increased drug-drug interactions.
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4
Q

UTI

A
  • Most healthy adults do not have bacteria in their bladder but some may have asymptomatic bacteria which does not require treatment
  • UTIs are the most common bacterial infection in women
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5
Q

UTI Risk Factors-

A
  • Immunosuppressed
  • Diabetic
  • Those taking multiple antibiotics
  • People who have traveled to developing countries
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6
Q

Etiology of UTI

A
  • Urinary tract is usually sterile. The tract stays sterile by complete emptying of bladder, competence of ureterovesical junction (prevents urine from refluxing out of bladder) and peristaltic activity.
  • Most commonly UTI’s are caused by E-coli
  • Strep and Staph can also cause UTI
  • Fungal and parasitic infections can also cause UTI
  • One cause of UTI is vesicoureteral reflux where urine flows backwards from the lower to the upper urinary tract
  • Instruments such as catheters with bacteria can also cause UTI’s
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7
Q

Classifications of UTI

A
  • Lower UTI includes bladder to urethra
    (Cystitis - Bladder)
    (Prostatitis - Prostate)
    (Urethritis - Urethra)
  • Upper UTI includes renal parenchyma, pelvis, ureters
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8
Q

Complicated vs Uncomplicated UTI

A

Uncomplicated - Usually involves only the bladder and no other issues
Complicated - Co-exists with obstructions, stones, catheters, diabetes, pregnancy, recurring infection

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9
Q

Acute Pyelonephritis

A
  • Upper UTI infection that is more severe than lower UTI
  • Observation of VS is important due to development of bacteria and possible urosepsis
  • Treatment must be prompt to prevent septic shock
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10
Q

Clinical Manifestations of UTI

A

Bladder Storage

  • Urinary frequency (more often than every 2 hours)
  • Urgency
  • Incontinence (leakage of urine)
  • Nocturia (Waking up 2+ times to void)
  • Nocturnal Enuresis (Loss of urine during sleep)

Bladder Emptying
- Weak stream or hesitancy to urinate

Other S/S

  • Dysuria (pain while urinating)
  • Lower abdominal pain/pressure
  • Cloudy or bloody urine
  • Fever/Nausea/Vomiting/Flank Pain = These can signal infection has reached kidneys
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11
Q

Diagnostic Tests for UTI

A
  • Dipstick Urinalysis - Identifies presence of nitrites, WBC, and leukocyte esterase
  • Microscopic Urinalysis - Identifies count and type of cells, casts, crystals, and other bacteria/mucus
  • Urine culture/sensitivity - Determines bacteria susceptibility to antibiotics for appropriate treatment
    (Can be taken with clean catch but catheter is or needle aspiration is more accurate)
  • Imaging Studies - CT urography, ultrasonography to check for obstructions
  • 24 hour urine collection
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12
Q

Interventions for UTI

A
  • Pain relief
  • Antibiotics/analgesics/antispasmodics
  • Application of heat to perineum to relieve pain and spasms
  • Increase fluid intake
  • Avoidance of urinary irritants (coffee, tea, spices, cola, alcohol)
  • Frequent voiding
  • Patient education
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13
Q

Drugs for UTI

A
  • Antibiotics - Parental administration to rapidly establish high drug levels. Drugs based off sensitivity testing. Uncomplicated takes 1-3 days and complicated takes 7-14 days
  • NSAIDs/Antipyretics - For fever and pain
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14
Q

Phenazopyridine (Pyridium)

A
  • Urinary analgesic used in combination with antibiotics
  • Soothes Urinary Tract Mucosa
  • Does not treat infection
  • Can turn urine red/orange
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15
Q

Issues with UTI

A
  • Sepsis (Urosepsis)
  • AKI
  • CKD
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16
Q

Urinary Tract Obstruction

A
  • Complete/partial blockage that can lead to renal damage, kidney stones, infection

S/S

  • Pain on the side
  • Decreased/Increased urine flow
  • Nocturia

Symptoms are more common when there is a complete sudden blockage.
- Source of blockage is identified and management is based off the cause

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17
Q

Urinary Tract Calculi (Nephrolithiasis)

A

Kidney Stones

  • More common in men except struvite
  • Common age of onset is 20-55
  • Reoccurrence is common (50%)
  • More common in Caucasian and Southern US (due to dehydration)

Calcium based - (Oxalate and Phosphate)
Uric Acid based
Struvite based - More prominent in women than men
Cystine based - Genetic

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18
Q

Etiology of Nephrolithiasis

A
  • Unknown

- Can be caused by metabolic, genetic, climate, lifestyle, occupational influences

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19
Q

Pathophysiology of Nephrolithiasis

A
  • Crystal that forms from what kidneys normally excrete
  • Made up of calcium, oxalate, urate, cystine, xanthine, phosphate
    HOW ITS FORMED
  • First a nucleus forms (Nidus)
  • Supersaturation of one or more salts, precipitation of salts from liquid to solid (usually caused by pH, alkaline for calcium and phosphate, acidic for uric acid stones) and growth/aggregation of the stone.
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20
Q

Manifestations

A
  • SUDDEN AND SEVERE PAIN IS THE FIRST SYMPTOM
  • Renal colic pain (stretching, dilation, spasm of ureter in response to obstructing stone. Acute intermittent pain in the flank/upper outer quadrants and can radiate to the lower abdomen)
  • Non-colicky pain (dull deep ache of flank/back. Can be exacerbated with drinking a lot of water)
  • Urgency/Frequency/Incontinence
  • Hematuria
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21
Q

Diagnostic Tests for Kidney Stones

A
  • Renal colic patients will receive non-contrast spiral CT
  • Ultrasonography
  • Intravenous Pyelography (IVP)
  • Complete urinalysis to assess hematuria and crystalluria
  • Retrieval and analysis of stone
  • Serum calcium/phosphorous/sodium/potassium/bicarbonate/uric acid/BUN/creatinine
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22
Q

Management of Kidney Stones

A
  • Pain management
  • Strain urine and send debris to lab
  • Dietary modifications
  • Treat infection
  • Lithotripsy (surgery to remove stones that are either associated with bacteria, cause renal impairment, too big to pass, or cause persistent pain)
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23
Q

Benign Prostatic Hyperplasia (BPH)

A
  • Prostate gland enlargement
  • Men’s prostate gland enlarges (common condition as men ages)
  • Prostate is located directly under the bladder, and enlargement can cause obstruction to the urethra and cause UTI or other renal issues
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24
Q

BPH Manifestations

A
  • Frequency/Urgency
  • Nocturia
  • Difficulty to start urinating
  • Weak urine stream (starts and stops)
  • Dribbling at the end of urination
  • Inability to empty bladder
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25
Q

BPH Management

A
  • Lifestyle changes such as limiting beverages at night and avoiding caffeine, alcohol, decongestants, or antihistamines. Void when the urge to is first felt
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26
Q

BPH Medications

A
  • Alpha Adrenergic Blockers - Tamsulosin, Alfuzosin, Terazosin. Used to relax prostate muscles but does not effect prostate size. Relieves urinary obstruction. Can cause headaches, fatigue, problem ejaculating, or lightheadedness
  • 5-alpha reductase inhibitors - blocks conversion of testosterone to DHT. DHT is what causes prostate enlargement. Can cause reduction in size of prostate. (Finasteride, Dutasteride)
  • Combination of the 2 can be used together
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27
Q

BPH Surgery

A
  • Transurethral Resection of Prostate
  • Instrument is put into urethra through the penis to shave away parts of the inner prostate
  • Lasers can also be used to remove prostate tissue and causes less bleeding
  • Microwaves can be used to kill prostate cells causing it to shrink
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28
Q

BPH Pre/Post Op

A

PREOP
- Antibiotics for existing UTI, teaching of catheters, teaching of continuous bladder irrigation in post-op
POSTOP
- Continuous bladder irrigation (monitor for bleeding or clots) clots are expected in the first 24-36 hours. Manually irrigate to relieve clots or blockage of the catheter
- Bladder irrigation is done through 3 way foley catheter with normal saline. Flow rate should maintain a rose color of the fluid and done for 24-48 hours. Monitor for infection, catheter care, frequent urination and erectile dysfunction.

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29
Q

Erectile Dysfunction (ED)

A
  • Impotence
  • Inability to sustain erection
  • Can be caused by age, prostate surgery, chronic illness
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30
Q

Sildenafil (Viagra)

A
  • Originally used for pulmonary hypertension
  • Can be dangerous if used with other vasodilators (alpha adrenergic blockers and nitrates)
  • Absorption is slowed by high fat meals
  • Can cause Hypotension, dyspepsia, flushing, priapism, nasal congestion, obstructive sleep apnea. Can also rarely cause optic neuropathy, and hearing loss.

INTERACTIONS
Nitrates - cause life threatening hypotension
Alpha Blockers - Postural Hypotension

SILDENAFIL SHOULD NOT BE TAKEN BY PATIENTS TAKING NITROGLYCERIN OR OTHER NITRATES
- DO NOT TAKE IF HF, HYPO/HYPERTENSION, OR UNSTABLE ANGINA

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31
Q

Other ED Medications

A

PDE5 Inhibitor 2 - Vardenafil and Tadalafil

Alprostadil - Injected directly into penis

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32
Q

Acute Kidney Injury (AKI)

A
  • Acute Renal Failure
  • Rapid loss of kidney function with rise in serum creatinine and reduction in urine output
  • Accumulation of nitrogenous waste, BUN and Creatinine in blood (azotemia). Reversible but mortality rate is high.
33
Q

Azotemia

A
  • Caused by AKI

- Accumulation of nitrogenous waste, BUN, and creatinine in blood

34
Q

Causes of AKI

A
  • Hypovolemia/Hypotension
  • Reduced Cardiac Output
  • HF
  • Obstruction of kidneys/lower urinary tract
  • Obstruction of renal arteries/veins
35
Q

Prerenal causes of AKI

A
  • External causes that reduce blood flow to kidneys
  • Dehydration/Hypovolemia/Hemorrhage/Decreased Perfusion/HF/Reduced Cardiac Output
  • These cause decrease in GFR and cause oliguria (less than 400 mL urine per day)
  • Reversal may be possible with fluid replacement
36
Q

Intrarenal Causes of AKI

A
  • Direct damage to Kidney Tissue
  • Prolonged ischemia, nephrotoxic drugs, trauma (crush injuries) which cause hemolyzed RBC’s and myoglobin to circulate and damage renal tissue.
37
Q

Acute Tubular Necrosis (ATN)

A
  • Death of tubular epithelial cells from renal tubules
  • Most common cause of AKI
  • Caused by ischemia (kills basement membranes) and nephrotoxic drugs (kills tubular epithelial cells)
  • Reversible if ischemia does not kill basement membranes
38
Q

Acute Glomerulonephritis

A
  • Inflammation of glomeruli caused by immunologic processes
  • Can develop after strep (APSGN - Acute Poststreptococcal GlomeruloNephritis)
  • Can also be caused by pyelonephritis (inflammation of renal parenchyma and collecting system)
39
Q

Chronic Glomerulonephritis

A
  • Repeated acute glomerulonephritis, hypertensive nephrosclerosis or hyperlipidemia
  • Results in renal insufficiency and go asymptomatic for years
  • Labs include fixed specific gravity, casts, proteinuria, electrolyte imbalances, hypoalbuminemia
40
Q

Acute Nephritic Syndrome

A
  • Results from post-infectious glomerulonephritis
  • INFLAMMATION
  • Hematuria, edema, azotemia, proteinuria, hypertension
  • Treated with diet modification, antibiotics, corticosteroids, and immunosuppressants
41
Q

Nephrotic Syndrome

A
  • Anything that damages glomerular membrane leading to increased permeability of plasma proteins
  • Results in hypoalbuminemia and edema
  • Managed through drug and diet therapy
  • PROTEIN IN URINE
42
Q

Post-Renal

A
  • Caused by obstruction from bladder cancer, prostate cancer, BPH (benign prostatic hypertrophy), calculi, trauma, extrarenal tumors.
43
Q

STAGES OF AKI

A
44
Q

Oliguria Stage

A
  • Occurs 1-7 days after injury and lasts 7-14 days
  • Urine output less than 400 mL a day
  • Urinalysis may show cast, RBC’s, and WBC’s
  • Fluid overload can cause HF, pulmonary edema, pericardial/pleural effusion
  • Can cause metabolic acidosis with decreased bicarbonate and kussmaul respirations
  • Increased excretion of sodium which leads to hyponatremia and cerebral edema
  • Potassium excess can go unnoticed but can cause ECG changes
  • Can cause leukocytosis
  • Elevated BUN and Serum Creatinine
  • Can cause fatigue/difficulty concentrating/seizure/stupor/coma
45
Q

Nursing Management Oliguria Stage

A
  • Monitor I&O
  • Determine dietary adjustment (low potassium if they are high in potassium, and determine if protein should be limited)
  • Determine need for hemodialysis (acute) or peritoneal dialysis (chronic)
46
Q

Diuretic Phase

A
  • Occurs when AKI is corrected
  • Daily urine output is 1-3 liters a day and may reach 5L or more
    MONITOR FOR
  • Hyponatremia
  • Hypokalemia
  • Dehydration
47
Q

Recovery Phase

A
  • May take 12 months to recover but BUN and Serum Creatinine should decrease
48
Q

AKI Diagnostics

A
  • Assessing cause of dehydration
  • Serum Creatinine (not evident until 50%+ loss of kidney function)
  • Urinalysis (osmolarity, sodium, specific gravity, urine sediment, hematuria, pyuria (pus in urine), crystals
  • Kidney Ultrasonography IS THE FIRST TEST DONE
  • Renal scan to check abnormal blood flow, tubular function and collecting system
  • CT scan to identify any lesions or masses
  • BIOPSY IS THE BEST WAY TO DETERMINE INTRARENAL CAUSES
  • Contrast Induced Nephropathy (CIN) is when the contrast used causes kidney damage. PREVENT THIS
49
Q

AKI Care

A
  • Reversible
  • Adequate fluid intake and output managed with diuretics
  • Monitor fluids during oliguria phase and check for lung crackles, or fluid overload
  • Hyperkalemia is the most serious electrolyte disorder in AKI
    (Administer insulin and sodium bicarbonate to push potassium back into cell)
  • Calcium gluconate can be given to prevent heart damage
  • Sodium Polystyrene can be given to eliminate potassium from the body
50
Q

Chronic Kidney Disease (CKD)

A
  • Leading cause of End Stage Kidney Disease (ESKD)
  • Associated with hypertension and diabetes
  • Irreversible loss of kidney function
  • GFR less than 60 mL/min for longer than 3 months
51
Q

Renal Insufficiency

A
  • Poor function of kidneys due to poor blood flow to kidneys
52
Q

Blood Studies for CKD

A

BUN - Concentration of urea (product of protein metabolism) in the blood. Not specific for renal function. Normal value is 10-20. Increase can also be caused by increased protein intake, fever, corticosteroids, and catabolic states.
Creatinine - End product of muscle and protein metabolism. Normal level is 0.6-1.1. Elevated in renal disease.
GFR - Amount of blood filtered by glomeruli each minute. Creatinine and GFR is the best way to calculate kidney function.
Serum Creatinine - Calculated GFR is more accurate than creatinine for kidney function. When adults age, there is a natural decline in GFR so creatinine is more preferred in these cases.

53
Q

CKD STAGING

A 
Stage 1 - Normal between 90-120 
Stage 2 - Normal between 60-90 
Stage 3 - Between 30-60
Stage 4 - Between 15-30
ESKD (Stage 5) - Between 0-15
54
Q

Patient History for CKD

A
  • History of diabetes/hypertension
  • Risk for contrast-associated nephrotic injury
  • Assess hydration and hyperkalemia (most serious imbalance for CKD)
55
Q

Clinical Manifestations of CKD

A
  • Uremia (elevated urea in the blood)

- Incorporates all signs and symptoms seen in various body systems

56
Q

Urinary System CKD Manifestations

A
  • Polyuria due to kidneys not being able to concentrate urine.
  • Occurs at night
  • Urine specific gravity is fixed at 1.010
  • Oliguria (less than 400 mL) happens when CKD becomes worse
  • Anuria urine output less than 40 mL in a day
57
Q

Metabolic CKD Manifestations

A
  • Altered Carbohydrate Metabolism - Impaired glucose metabolism can cause insulin resistance.
  • Can cause hyperglycemia and hyperinsulinemia
  • Dialysis can help but will not return glucose or insulin to normal values
  • Diabetes patients with CKD may require less insulin because the kidneys cannot excrete it as well, meaning it stays in circulation for longer
  • Patients who need insulin before dialysis may not need it when they start dialysis
  • Hyperinsulinemia causes higher triglyceride levels
  • Lipid metabolism is altered due to less lipoprotein lipase (used to breakdown lipoprotein)
58
Q

Electrolyte/Acid-Base Imbalance

A
  • Hyperkalemia is the most dangerous causing dysrhythmias
  • Hypernatremia due to impaired excretion causing edema, HTN, HF
  • Metabolic Acidosis due to inability to excrete acid and retain bicarbonate
59
Q

Respiratory System CKD

A
  • Kussmaul Respirations from acidosis
  • Dyspnea from fluid overload
  • Pulmonary edema from fluid overload
  • Respiratory Infection
  • Uremic Pleuritis
60
Q

GI CKD Manifestations

A
  • Excess urea affects all areas of GI
  • Mucosal Ulceration
  • Stomatitis
  • Uremic Fetor (odor of urine in breath)
  • GI Bleed
  • Anorexia/Nausea/Vomiting/Constipation
61
Q

Neurological System CKD Manifestations

A
  • Altered Mental Status
  • Seizure
  • Coma
  • Dialysis Encephalopathy
62
Q

Integumentary and Musculoskeletal CKD Manifestations

A

Skin
- Pruritis, Uremic Frost (metabolic waste through skin)

Musculoskeletal
- CKD Mineral and Bone Disorder (CKD-MBD) Bone Remodeling that causes softening of bones (osteomalacia) and vascular calcification

63
Q

Dialysis

A
  • Substances/toxins removed from body through semi-permeable membrane into dialysis solution (dialysate)
  • Used in ESKD to correct fluid/electrolytes and remove waste products
  • Used when uremia can no longer be managed or when GFR falls below 15 mL/min
64
Q

Principles of Dialysis movement of fluids

A
  • Diffusion (solutes move from greater concentration to lower concentration
  • Osmosis (Water moves from lower concentration to greater concentration solutes)
  • Ultrafiltration (water and fluid removal due to osmotic gradient over membrane)
65
Q

Peritoneal Dialysis

A
  • Catheter is inserted through the abdominal wall
  • Preparation for catheter placement includes emptying bowels and bladder, weighing patient, and obtaining consent form
  • Wait 7-14 days after catheter insertion before using it
  • Site should be healed in 2-4 weeks where patients can shower and pat the insertion site dry
  • Showering is preferred over baths because catheter cannot be submersed in water.
  • Check insertion site daily for redness, swelling, drainage or tenderness
66
Q

PD Cycle

A

Inflow - Solution (dialysate) is infused into catheter over 10 minutes then inflow clamp is closed to prevent air from entering the tube

Dwell (equilibration) - Diffusion and osmosis occur between blood and peritoneal cavity which can last anywhere between 20 minutes to 8 hours

Drain - 15-30 minutes where fluid is drained out of peritoneal cavity via gravity. Massaging the abdomen or position change can make this step quicker

PERITONITIS - Cloudy drainage which should be reported

67
Q

Automated Peritoneal Dialysis (APD)

A
  • Allows patient to do dialysis while they sleep so it is preferred
  • Machine can do 4+ cycles a night taking 1-2 hours per exchange
68
Q

Continuous Ambulatory Peritoneal Dialysis (CAPD)

A
  • Manually done 4 times a day
69
Q

Complications of PD

A
  • Exit Site Infection (nurses should assess clients understanding that this needs to be a sterile technique. The most common bacteria for infection is strep and staph)
  • Peritonitis - Cloudy drainage. Obtain specimen for culture/sensitivity. Most often happens due to improper technique
  • Hernia - Due to intraabdominal pressure during dialysate infusion. More common in obese or multiparous women and older men.
  • Lower back problems - due to intraabdominal pressure from dialysate
  • Bleeding
  • Pulmonary complications such as atelectasis, pneumonia, bronchitis due to repeated displacement of diaphragm
  • Protein loss
  • Advantages include only taking 3-7 days to learn, increased patient independence, improved ease of traveling, greater mobilization, fewer dietary restrictions
70
Q

Hemodialysis

A
  • Artificial membrane made of cellulose
  • Blood is removed from a surgically created fistula via a catheter and pushed into a dialyzer
  • Dialysate is pumped in and flows opposite way of blood
  • Heparin is infused either as a pre-dialysis bolus or via heparin pump to prevent blood clotting in the machine
  • Blood is then returned to body and dialysate is drained/discarded
71
Q

Hemodialysis Issues

A
  • Most difficult issue is gaining vascular access
  • Types of access include arteriovenous fistulas/grafts, temporary catheters, or percutaneous cannulation of internal femoral and jugular vein for immediate access
  • AV fistulas have best patency and least complications
  • AV fistulas create a connection between an artery and a vein usually in the forearm
  • Takes 3 weeks for fistula to heal and be used
  • Patency is assessed via palpable thrill or auscultated bruit
72
Q

Hemodialysis

A
  • 2 needles, 1 to take blood out and 1 to put blood back in

- Dialyzer and blood lines need to be primed with saline to eliminate air

73
Q

Hemodialysis Nursing Care

A
  • Protect vascular access (patency, infection, do not check BP on that arm or draw blood)
  • Monitor fluid balance, IV therapy, I&O
  • Monitor signs of uremia, electrolyte imbalance
  • Monitor cardiac/respiratory status carefully
  • Cardiovascular medications must be held prior to dialysis
74
Q

Diuretics

A
  • In CKD it is used to treat edema, lower BP, and lower potassium in hyperkalemia patients
75
Q

Furosemide (Lasix) - Bumetanide (Bumex)

A
  • Loop Diuretic
  • Blocks reabsorption of sodium and chloride which prevents reabsorption of water in the loop of Henle.
  • Used for BP management and mobilization of fluids for pulmonary edema

NURSING INTERVENTIONS

  • Monitor BP, potassium (note decrease in potassium) especially for digoxin toxicity
  • Can cause ototoxicity after rapid IV infusion (monitor tinnitus and balance disturbances)
  • Can cause hypomagnesemia (Monitor weakness, muscle twitching, tremors)
  • Monitor weight
  • Educate patient on foods high in potassium and risk of orthostatic hypotension
76
Q

Hydrochlorothiazide (HCTZ, HydroDiuril)

A
  • Thiazide Diuretic
  • Block sodium and chloride reabsorption thereby preventing water reabsorption in the early distal convoluted tubules.
  • First drug of choice for HTN, also used for moderate HF
    NURSING INTERVENTIONS
  • Assess signs of dehydration and electrolyte imbalance
  • Monitor for increased blood glucose
  • 2 doses a day, 2nd dose should be before 2pm to prevent nocturia
  • Educate patient on monitoring BP and weight
  • Does not cause ototoxicity x
77
Q

Spironolactone (Aldactone)

A
  • Potassium Sparing Diuretic
  • Blocks aldosterone which in turn eliminates sodium and water and retains potassium
  • Can be used with loop or thiazide diuretics
  • ACE inhibitors, Angiotensin Receptor Blockers, and Direct Renin Inhibitors can cause elevated potassium
  • If used with potassium supplements, hyperkalemia is at risk
78
Q

Mannitol (Osmitrol)

A
  • Osmotic Diuretic
  • Given via IV to raise serum osmolarity which draws fluid back into vascular and extravascular spaces. Pulls water into the tubules along with electrolytes to be excreted
  • Reduces Intracranial Pressure and Intraocular Pressure
    RISKS
  • Contraindicated in head bleed, severe pulmonary edema, severe dehydration, and renal failure
  • Increased risk of hypokalemia with digoxin (cardiac glycoside)
  • Monitor lithium levels because it is excreted in urine

Older Adults Pt 2 (17 decks)

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