10.1 Renal Flashcards
Renal System
- Regulates fluid and electrolytes
- Removes wastes
- Provides hormones in RBC production, bone metabolism
- Controls BP
Normal Bladder
- 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
Older Adults Kidney Issues
- 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.
UTI
- 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
UTI Risk Factors-
- Immunosuppressed
- Diabetic
- Those taking multiple antibiotics
- People who have traveled to developing countries
Etiology of UTI
- 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
Classifications of UTI
- Lower UTI includes bladder to urethra
(Cystitis - Bladder)
(Prostatitis - Prostate)
(Urethritis - Urethra) - Upper UTI includes renal parenchyma, pelvis, ureters
Complicated vs Uncomplicated UTI
Uncomplicated - Usually involves only the bladder and no other issues
Complicated - Co-exists with obstructions, stones, catheters, diabetes, pregnancy, recurring infection
Acute Pyelonephritis
- 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
Clinical Manifestations of UTI
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
Diagnostic Tests for UTI
- 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
Interventions for UTI
- 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
Drugs for UTI
- 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
Phenazopyridine (Pyridium)
- Urinary analgesic used in combination with antibiotics
- Soothes Urinary Tract Mucosa
- Does not treat infection
- Can turn urine red/orange
Issues with UTI
- Sepsis (Urosepsis)
- AKI
- CKD
Urinary Tract Obstruction
- 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
Urinary Tract Calculi (Nephrolithiasis)
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
Etiology of Nephrolithiasis
- Unknown
- Can be caused by metabolic, genetic, climate, lifestyle, occupational influences
Pathophysiology of Nephrolithiasis
- 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.
Manifestations
- 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
Diagnostic Tests for Kidney Stones
- 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
Management of Kidney Stones
- 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)
Benign Prostatic Hyperplasia (BPH)
- 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
BPH Manifestations
- Frequency/Urgency
- Nocturia
- Difficulty to start urinating
- Weak urine stream (starts and stops)
- Dribbling at the end of urination
- Inability to empty bladder
BPH Management
- Lifestyle changes such as limiting beverages at night and avoiding caffeine, alcohol, decongestants, or antihistamines. Void when the urge to is first felt
BPH Medications
- 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
BPH Surgery
- 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
BPH Pre/Post Op
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.
Erectile Dysfunction (ED)
- Impotence
- Inability to sustain erection
- Can be caused by age, prostate surgery, chronic illness
Sildenafil (Viagra)
- 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
Other ED Medications
PDE5 Inhibitor 2 - Vardenafil and Tadalafil
Alprostadil - Injected directly into penis
Acute Kidney Injury (AKI)
- 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.
Azotemia
- Caused by AKI
- Accumulation of nitrogenous waste, BUN, and creatinine in blood
Causes of AKI
- Hypovolemia/Hypotension
- Reduced Cardiac Output
- HF
- Obstruction of kidneys/lower urinary tract
- Obstruction of renal arteries/veins
Prerenal causes of AKI
- 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
Intrarenal Causes of AKI
- 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.
Acute Tubular Necrosis (ATN)
- 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
Acute Glomerulonephritis
- 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)
Chronic Glomerulonephritis
- 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
Acute Nephritic Syndrome
- Results from post-infectious glomerulonephritis
- INFLAMMATION
- Hematuria, edema, azotemia, proteinuria, hypertension
- Treated with diet modification, antibiotics, corticosteroids, and immunosuppressants
Nephrotic Syndrome
- 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
Post-Renal
- Caused by obstruction from bladder cancer, prostate cancer, BPH (benign prostatic hypertrophy), calculi, trauma, extrarenal tumors.
STAGES OF AKI
Oliguria Stage
- 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
Nursing Management Oliguria Stage
- 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)
Diuretic Phase
- 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
Recovery Phase
- May take 12 months to recover but BUN and Serum Creatinine should decrease
AKI Diagnostics
- 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
AKI Care
- 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
Chronic Kidney Disease (CKD)
- 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
Renal Insufficiency
- Poor function of kidneys due to poor blood flow to kidneys
Blood Studies for CKD
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.
CKD STAGING
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
Patient History for CKD
- History of diabetes/hypertension
- Risk for contrast-associated nephrotic injury
- Assess hydration and hyperkalemia (most serious imbalance for CKD)
Clinical Manifestations of CKD
- Uremia (elevated urea in the blood)
- Incorporates all signs and symptoms seen in various body systems
Urinary System CKD Manifestations
- 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
Metabolic CKD Manifestations
- 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)
Electrolyte/Acid-Base Imbalance
- 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
Respiratory System CKD
- Kussmaul Respirations from acidosis
- Dyspnea from fluid overload
- Pulmonary edema from fluid overload
- Respiratory Infection
- Uremic Pleuritis
GI CKD Manifestations
- Excess urea affects all areas of GI
- Mucosal Ulceration
- Stomatitis
- Uremic Fetor (odor of urine in breath)
- GI Bleed
- Anorexia/Nausea/Vomiting/Constipation
Neurological System CKD Manifestations
- Altered Mental Status
- Seizure
- Coma
- Dialysis Encephalopathy
Integumentary and Musculoskeletal CKD Manifestations
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
Dialysis
- 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
Principles of Dialysis movement of fluids
- 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)
Peritoneal Dialysis
- 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
PD Cycle
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
Automated Peritoneal Dialysis (APD)
- 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
Continuous Ambulatory Peritoneal Dialysis (CAPD)
- Manually done 4 times a day
Complications of PD
- 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
Hemodialysis
- 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
Hemodialysis Issues
- 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
Hemodialysis
- 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
Hemodialysis Nursing Care
- 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
Diuretics
- In CKD it is used to treat edema, lower BP, and lower potassium in hyperkalemia patients
Furosemide (Lasix) - Bumetanide (Bumex)
- 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
Hydrochlorothiazide (HCTZ, HydroDiuril)
- 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
Spironolactone (Aldactone)
- 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
Mannitol (Osmitrol)
- 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
