2.5 Renal/Urinary Flashcards
Major Functions of Kidneys
Regulatory functions
Regulatory functions:
Fluid & electrolyte balance
acid-base balance (through Bicarbonate reabsorption)
Done through urine elimination, glomerular filtration, tubular reabsorption and tubular secretion.
**Healthy renal system depends on health of other body systems especially circulatory, endocrine, & nervous systems.
Major Functions of Kidneys
Hormonal functions
Hormonal functions:
Renin production: assists in B/P control
Prostaglandin production: assists in regulation of glomerular filtration, renin production, increases H20 & Na excretion.
Erythropoietin: triggers RBC production in response to decreased O2 in kidneys blood.
Vit D activation: kidneys convert Vit. D to its active form which helps regulate calcium balance.
**Healthy renal system depends on health of other body systems especially circulatory, endocrine, & nervous systems.
Fluid & electrolyte balance via urine elimination & glomerular filtration
Acid-base balance
Waste excretion
Blood pressure regulation (Renin)
Red blood cell production (Erythropoietin)
Regulation of Ca/Phos metabolism
(activates vitamin D, enhances Calcium absorption)
Age related changes to renal system
Physiologic Changes:
GFR, NI, Rational
Decreased GFR NI: Monitor hydration status Ensure adequate fluid intake Use caution when administering nephrotoxic agents.
Rationales:
Kidneys ability to regulate water balance decreases with age, less able to conserve water when needed, dehydration reduces kidney blood flow and increases nephrotoxic potential of meds.
Age related changes to renal system
Physiologic Changes:
Nocturia, NI, Rational
Nocturia NI: Ensure nighttime lightening Availability of commode/ urinal Discourage excessive fluid intake 2-4hr before bed Evaluate drugs and timing
Rational:
Falls common while going to BR
Excessive fluid intake can increase nocturia.
Some drugs increase urine output.
Age related changes to renal system
Physiologic Changes:
Bladder, NI, Rational
Decreased bladder capacity
NI:
Encourage void q 2 hr.
Respond to pts. Need to void.
Rational:
Emptying bladder regularly avoids overflow incontinence.
Quick response alleviates stress incontinence.
Age related changes to renal system
Physiologic Changes:
Sphincter/urethra, NI, rational
Weakened urinary sphincters & shortened urethra in women
NI:
Provide through perineal care after each voiding.
Rational:
Shortened urethra increases risk for bladder infections.
Good hygiene may prevent skin irritations and UTI’s.
Age related changes to renal system
Physiologic Changes:
Urine retention, NI, rational
Tendency to retain urine
NI:
Observe for urinary retention.
Provide privacy & voiding stimulants (warm water)
Eval for drugs cause retention
Rational:
Urinary stasis may result in UTI leading to urosepsis or septic shock.
Anticholinergic drugs promote urinary retention.
Renal Assessment- Recognizing Cues
Demographic info (age, gender etc.) identifies nonmodifiable risk factors of kidney disease.
Previous kidney or urologic problems
- Tumors, infections, stones
- HTN or DM (causes damage to kidney blood vessels).
Use of heroin, cocaine, methamphetamine, ecstasy etc. assoc. with kidney disease.
Chemical exposures- gasoline, oil, mercury lead.
Educational levels- affects level of understanding.
Home meds (nephrotoxic risk?)
Incontinence, nocturia, retention, cancer hx. etc.
Diet:
Amount & type of fluid intake. Caffeine??
Excessive protein calcium intake (can cause kidney stones)
Change in appetite/taste? Indicates buildup of nitrogenous waste products
What a kidney does?
Water?
Water:
ensures that there’s not too much or too little water in the body
What a kidney does?
Blood pressure?
Makes sure that presure isn’t too high or too low
What a kidney does?
Waste?
Gets rid of urea, uric acid, toxins, other wastes via urine
What a kidney does?
Bones?
Activates vit D which helps the body absorb calcium
What a kidney does?
Acid-base balance?
Makes sure that the body isn’t too acidic or too alkaline
What a kidney does?
Heart?
Maintains a balance of electrolytes, like potassium, sodium, calcium, which is critical for heart rhythm
What a kidney does?
Blood?
Releases erythropoietin which tells bone marrow to make red blood cells
Renin, what is it?
hormone secreted by kidneys helps regulate b/p
Renin, also called angiotensinogenase, is an enzyme involved in the renin–angiotensin aldosterone system (RAAS), which regulates the body’s water balance and blood pressure level. The system regulates the extracellular volume in the blood plasma, lymph and interstitial fluid, as well as controlling constriction of the arteries and blood vessels.
Renin is stimulated by three factors?
When a fall in arterial blood pressure is detected by pressure sensitive receptors (baroreceptors) in the arterial vessels.
When a decrease in sodium chloride (salt) is detected in the kidney by the macula densa in the juxtaglomerular apparatus.
When sympathetic nervous system activity is detected through beta1 adrenergic receptors.
Diagnostic Tests
Intravenous pyelogram retrograde pyelogram (IVP) MRI Bladder Scan Renal arteriogram or angiogram Renal biopsy Renal scan Renal Ultrasound UA Post-void residual Blood urea nitrogen (BUN) Creatinine (serum) Creatinine clearance Cystatin C CT scan Cystometrogram (CMG) Cystoscopy Glomerular filtration rate (GFR)
Kidneys, Ureter & Bladder (KUB) X-RAY
Identifies any gross anatomic features & obvious stones.
X-ray visualizes kidneys, ureters and bladder.
No specific prep needed.
More diagnostic tests needed to diagnose functional or structural problems.
Intravenous Pyelogram (renal pelvis) (IVP)
Radiologic exam that visualizes the entire urinary tract by using contrast dye to improve visualization.
Diagnoses kidney disorders ,detects renal calculi, tumors, or cysts.
Intravenous Pyelogram (renal pelvis) (IVP) NI?
Nursing Interventions Assess for iodine or seafood allergy NPO 8-12 prior clear liquids ok No oral hypoglycemic- contraindicated with dye Creatinine/ BUN levels IV access for dye injection
Oral hypoglycemic meds like metformin can cause lactic acidosis.
Metformin may interact with the dye used for an X-ray or CT scan. Your doctor should advise you to stop taking it before you have any medical exams or diagnostic tests that might cause less urine output than usual. You may be advised to start taking the medicine again 48 hours after the exams or tests if your kidney function is tested and found to be normal.
MRI of Kidneys
what is it?
NI?
Provides improved imaging between normal & abnormal tissue.
Nursing Interventions:
Assess for metal implants (pacemaker, joint replacements, aneurysm clips, cosmetic or medical devices).
Remove transdermal patches
Claustrophobia
Renal Arteriogram or Angiogram
Visualizes renal arteries using radiopaque dye.
Dye injected via femoral or brachial artery.
Seldom used as stand-alone diagnostic procedure.
Usually done at time of renal angioplasty or other intervention.
Renal Arteriogram or Angiogram
NI
Nursing Interventions
Assess dye allergy & anticoagulant use
NPO 8-12 h prior
Oral hypoglycemic’s contraindicated with contrast medium
Renal Arteriogram or Angiogram
Post procedure?
Post procedure: Monitor bleeding @femoral artery Restrict activity x 1 day Monitor output (dye is hard on kidneys) Monitor peripheral pulses
Renal Arteriogram or Angiogram
Metformin, how it interaction occurs?
How the interaction occurs:
If you are taking metformin when you have your imaging test procedure, your kidneys may not be able to properly remove metformin from your blood.
Renal Arteriogram or Angiogram
Metformin, what might happen?
What might happen:
The effects of metformin may increase and cause a serious condition called lactic acidosis, especially if you have kidney problems. Symptoms of lactic acidosis are: feeling very weak, tired, or uncomfortable, unusual muscle pain, trouble breathing, unusual or unexpected stomach discomfort, feeling cold, dizziness or lightheadedness, suddenly developing a slow or irregular heartbeat.
Renal Scan
Examines:
Perfusion, function & structure of the kidneys.
Uses IV radioisotope- contains no iodine, less kidney injury risk.
Renal Scan
NI
Nursing Interventions
Insert IV for isotope administration
Enc. Fluid intake to aide in isotope elimination.
Isotope generally eliminated within 6-24 hrs.
Renal Scan
Pre-procedure?
Pre-Procedure: Drink several glasses of water Obtain weight and have patient void Post-Procedure: Increase fluid intake
Kidney Biopsy
Helps determine cause of unexplained kidney problems guides care.
Performed percutaneously (through skin) with a biopsy needle using ultrasound/CT guidance.
Bleeding is a MAJOR risk.
Kidney Biopsy
NI
Nursing care:
Informed consent
NPO 4-6 hrs. before.
PT, PTT drawn prior r/t major risk of bleeding complication.
Manage B/P (HTN increases bleeding risk).
Strict bedrest 24 hrs. post biopsy. Limited bathroom privileges after 24 hr. if no evidence of bleeding.
Discomfort expected at biopsy site. If pain radiates to flank, back and abdomen suspect bleeding.
Monitor:
Urine output, hematuria, vital signs.
Bruising/flank pain (indicates internal bleed)
Cystometrography (CMG) AKA: voiding cystogram
Provides info about bladder capacity, pressure and voiding reflexes.
Cystometrography (CMG) AKA: voiding cystogram
procedure?
Procedure:
Pt. voids normally. Record amount and time of void.
Insert catheter to measure residual urine volume.
Cystometer attached to catheter and fluid is instilled (about 500 ml) into the bladder.
Pt. reports when 1st feeling urge to void is felt & the point when strong urge to void is felt.
Bladder capacity & pressure readings are recorded.
Bladder capacity?
Urge?
Fullness?
Bladder capacity is about 300-600 ml’s.
Urge to void sensed @ >150ml
Fullness sensed @ 300 ml
Urodynamic studies: examine the processes of voiding and includes
Tests of bladder capacity, pressure and tone
Studies of urethral pressure and urine flow
Tests perineal voluntary muscle function.
Includes CMG (Cystometrogram), urethral pressure profile (UPP) urine stream testing (evaluates pelvic muscle strength). EMG (Electromyography) of perineal muscles to test strength of muscles used in voiding
Cystoscopy
Evaluates bladder, urethra and lower portions of ureters.
Endoscope inserted through urethra into the bladder.
Requires pre-op checklist and informed consent.
Performed for diagnosis or treatment of:
Bladder trauma
Identify causes of urinary tract obstructions.
Remove bladder tumors or implant radium seeds into a tumor.
Stop areas of bleeding
Resect an enlarged prostate gland.
Cystoscopy
Post op care
Post-op care:
Monitor airway patency & breathing.
Urine may be pink tinged. Gross bleeding not expected.
Monitor urine output. Enc. Fluids to decrease burning sensation.
Urinary frequency expected initially due to irritation from procedure.
Monitor for s/s bladder puncture- severe pain (including abdominal pain) nausea and vomiting.
**Cystoscopy can be done under general or local anesthetic with conscious sedation. Done in surgery, outpatient clinics and doctors offices.
Cystatin C
Measures glomerular filtration rate.
Is a protein produced in the body at a constant rate & can be used as indicator of GFR.
When GFR is reduced cystatin-c increases
Increased levels can be considered a predictor of chronic renal disease.
Not influenced by factors that influence BUN and creatinine. Maybe be better indicator of GFR.
Increased blood concentration = indicate decrease GFR & kidney dysfunction.
Nursing Interventions:
No specific preparation is required.
Blood Urea Nitrogen (BUN)
Measures effectiveness of kidneys excretion of urea nitrogen.
Urea nitrogen is by-product of protein breakdown in the liver.
Kidneys filter urea nitrogen from the blood and excrete in the urine.
Elevated BUN does not always mean kidney disease is present.
Normal range 10-20 mg/dl. Slightly higher in older adults.
Blood Urea Nitrogen (BUN)
factors that increase BUN?
Contributing factors to increased BUN levels:
Rapid cell destruction from infection, cancer Tx., or steroid therapy.
Blood (protein) from injured tissues.
Dehydration
Urea is an end product of what?
Urea is an end product of protein metabolism. An elevated BUN level could be indication of dehydration, prerenal failure, or renal failure or GI bleeding. Dehydration from vomiting diarrhea or inadequate fluid intake is common cause of elevated BUN. If dehydration after hydrated the BUN should return to normal if not prerenal or renal failure should be suspected. Digested blood from GI bleeding is a source of protein and can cause the BUN to elevate. A low BUN usually indicates over hydration (hypervolemia).
Serum Creatinine-
Blood test that evaluates kidney function.
Creatinine is produced when muscles & other proteins are broken down & excreted by the kidneys.
Higher in men vs women r/t larger muscle mass.
Normal value: 0.5-1.2 mg/dl
Kidney disease is the only condition that raises serum creatinine.
When serum creatinine levels doubled, it indicates a 50% reduction in GFR.
Kidney function properly?
Kidney not function?
Regarding serum creatinine
If kidneys are functioning properly you’d expect to see higher levels of creatinine in urine and less in blood. When kidneys do not function well less creatinine is seen in urine and more in the blood.
Serum Creatinine clearance/Glomerular Filtration Rate (GFR)
Best test to measure level of kidney function
Determines stage of kidney disease.
Calculated by blood creatinine, age, body size, and gender.
Low numbers mean kidney is not working well.
24 hr. Urine Creatinine Clearance
Urine sample that is collected for 24 h period of time.
Evaluates GFR & renal function.
Done along with serum creatinine
Normal 85-135
Expect low levels if kidney function impaired.
Thought: “kidneys clear creatinine from blood”
So higher levels would be seen in urine of normal kidneys
24 hr. Urine Creatinine Clearance
NI
Nursing Interventions:
First urine is discarded
Keep urine on ice or in refrigerator during 24h period (unless preservative in the container)
Instruct pt. and family to save all urine during 24h
Assess meds: thiazides steroids may decrease creatinine while Methyldopa, vit c, cimetidine may increase levels.
How is creatinine removed from kidney?
Creatinine is removed, or cleared, from the body entirely by the kidneys. If kidney function is abnormal, creatinine level increases in the blood because less creatinine is released through the urine.
Urinalysis (UA)
UA part of a physical exam. Provides useful info for pts. with suspected kidney disorders.
Ideally collected 1st morning urine. Other specimens may be too dilute.
Specimens become more alkaline when left unrefrigerated for more than 1 hr. or when bacteria are present. Promptly cover and deliver to the lab.
Significant Components of a UA
Color?
Normal?
Abnormal?
Yellow
Dark amber= concentrated urine
Very pale yellow= dilute urine
Dark red or brown= indicates blood or increased bilirubin
Significant Components of a UA
Turbidity
Normal?
Abnormal?
Clear
Cloudy= infection, sediment or protein present.
Significant Components of a UA
Specific gravity?
Normal?
Abnormal?
1.005-1.020
Increased= decreased kidney perfusion, HF,
Decreased= CKD, Diabetes,
Significant Components of a UA
Protein
Normal?
Abnormal?
0=8 mg/dl
Protein is not normally present in urine r/t molecules being too large to pass through intact glomerular membranes.
Increased = glomerular disorders, stress, infection or recent strenuous exercise.
Significant Components of a UA
Leukocyte esterase
Normal?
Abnormal?
None
Presence suggests UTI
Significant Components of a UA
Nitrates
Normal?
Abnormal?
None
Presence suggests urinary Escherichia coli
Chronic Pyelonephritis
Think Infection!!!!!
Repeated upper UTIs occurring in patients who almost exclusively have anatomic abnormalities of the urinary tract.
Urinary stasis, reflux from bladder tumors/enlarged prostate
Kidney stones
Acute Pyelonephritis:
An active bacterial infection.
Involves acute tissue inflammation, local edema & cell necrosis.
Onset usually rapid
s/s chills, fever, malaise, vomiting, flank pain, frequency, dysuria, costovertebral tend
Chronic Pyelonephritis:
Repeated infections causing scar tissue to develop from chronic inflammation in the kidney glomerular and tubular structures.
Results in impaired reabsorption and kidney function is reduced.
Conditions causing chronic pyelonephritis:
Conditions causing chronic pyelonephritis:
Kidney stones, scaring from pelvic radiation, reflux, diabetic neuropathy, SCI(Acute spinal cord injury), neurodegenerative diseases (MS, spina bifida). E-coli urine infections, immune diseases that cause systemic inflammatory response (lupus).
Chronic Pyelonephritis
Assessment findings
Assessment findings:
May be asymptomatic
Mild urinary frequency, dysuria, & flank pain
Frequent s/s is HTN as kidney tissue is destroyed
Chronic Pyelonephritis
Predisposing factors
Predisposing factors: UTI’s HTN or vascular conditions Obstructions of urinary tract (stones) Acute pyelonephritis looks like an infection Chronic looks like kidney failure
Chronic Pyelonephritis
develops?
Chronic Pyelonephritis
Common cause of CKD
May develop r/t UTI’s or other conditions that damage kidneys such as HTN or vascular conditions, obstructions, reflux.
May be asymptomatic or have mild manifestations (frequency, dysuria, flank pain)
HTN may occur as kidney tissue is destroyed.
Diagnostic’s for Pyelonephritis
Radiologic imaging IVP CT Voiding cystourethrography (CMG) Cystoscopy **Radiologic imaging looks for functional or structural abnormalities of kidneys, ureters, and bladder.
Urinalysis to assess for
Urinalysis to assess for
Pyuria
Bacteria
Blood in urine
Bacteria count >100,000 indicative of infection
Urine dipsticks identify nitrates & leukocytes (indicative of bacteria in urine)
NI for Chronic Pyelonephritis
Teach measure to prevent UTI
Encourage fluid intake
Avoid holding urine when urge to go
Teach Vit. C and Cranberry juice intake. Why?
Avoid excess milk and milk products (renal stone risk)
Teach importance of reporting change in urine color, clarity, of s/s of infection.
PH urine increases (more alkaline) with age making more prone to UTI’s.
Prevention of UTI
UTI prevention: void before and after sex, wipe front to back. Avoid bubble baths, vaginal douches, feminine sprays, cranberry juice and vitamin c to increase acidity of urine.
What increases change of renal calculi
Milk and milk products increase chance of renal calculi r/t increased calcium levels
Glycosuria
Glycosuria also more common in older adults due to high incidence of diabetes in this population. Sugar in urine makes good breeding ground for bacteria.
Glomerulonephritis
What is it?
Inflammation of the glomerular capillary membrane in the kidney.
Glomerulus functions:
Glomerulus functions:
Water & electrolytes pass freely across this membrane
Larger molecules (plasma proteins & RBC) do not cross this membrane and are retained in the blood.
Inflamed glomeruli allows passage of large products (RBC & protein) to pass through & are present in the urine.
Chronic Glomerulonephritis
Think Immune Reaction!!!
Develops over years to decades.
Always leads to end-stage kidney/renal disease (ESKD/ ESRD).
Exact cause unknown, but changes in kidney tissue result from:
- Inflammation from -immunity excess (Lupus)
- Infection.
- Hypertension
- Poor kidney blood flow.
- Diabetic nephropathy- leading cause of CKD (r/t elevated BS causes scaring to the kidney & increases the speed of blood flow into the kidney placing strain on the filtering glomeruli & raising B/P).
Lupus and kidneys
Lupus causes inflammation of connective tissue in the body. The inflammatory process in lupus causes damage to the kidneys particularly the glomerulus.
Diabetic Neuropathy
Leading cause of glomerular disease and TKF
Caused by elevated levels of blood glucose
Scarring the kidney
Elevated glucose levels increase speed of blood flow into kidney, putting strain on filtration and raising B/P
Chronic Glomerulonephritis
Let’s think about it
Glomerulus is basic filtration system of the kidneys
Damage to glomerulus= increased capillary permeability leads to membrane more permeable to proteins and blood cells.
Diagnostic findings – Chronic Glomerulonephritis
UA- + RBC & + protein (1st indicator of disease) BUN increased Serum Creatinine increased Urine Creatinine decreased GFR decreased Oliguria (output <400ml/24h) Edema- protein loss causes fluid shift to interstitial spaces. HTN- Na & water retention Hyperkalemia
Chronic Glomerulonephritis Assessment/symptoms
changes in elimination pattern: frequency, color, odor, clarity, nocturia (common). Frothy urine caused by proteinuria
Recent infections (streptococcal).
Exposure to nephrotoxic medications.
Previous transfusion reaction, DM, HF.
Fluid overload can occur with decreased urine output.
Assess:
SOB, lung sounds for crackles
Respiratory rate, B/P, weight, edema.
For s/s of uremia: slurred speech, tremors, skin rashes, bruises, itching or dryness.
NI Chronic Glomerulonephritis
Monitor vitals for s/s of fluid excess. B/P mgmt. essential! (tachycardia, HTN, weight gain, lung sounds= crackles)
Document energy level- energy increases with improved glomerular filtration.
Na+ restriction if edema or HTN (as ordered)
Dietary protein restriction if azotemia (kidneys are no longer able to get rid of enough nitrogen) present. Instruct only complete proteins
Complete proteins: milk, eggs, cheese, meat poultry, fish, soy.
Incomplete proteins: veggies, bread, cereals, grains, seeds nuts, legumes.
NI Chronic Glomerulonephritis
Monitor use of diuretics – decrease edema but leads to electrolyte imbalances causing increased fatigue.
Teach avoidance of nephrotoxic medications
Monitor WBC’s- increase in immature WBC’s indicative of infection.
ACE or ARB’s (have protective effect on kidneys) may be ordered to reduce protein loss and slow progression of renal failure.
Chronic Chronic Kidney Disease (CKD)
Progressive irreversible loss of kidney function
Classified into 5 stages based on GFR category.
Presence of kidney damage or GFR<60 ml/min lasting> 3 months.
CKD with greatly reduced GFR causes abnormal urine production, disruption of fluid & electrolytes and metabolic abnormalities.
Chronic Chronic Kidney Disease (CKD)
predisposing factors
Predisposing Factors:
Significantly higher in 65 and older group.
Cultural variances- African American highest incidence.
Diabetes is leading cause, followed by HTN, glomerulonephritis, and cystic kidney disease
ESRD the GFR is <10% of normal
Urinary System Changes with Renal Failure.
three stages
Early
Later
Final
Urinary System Changes with Renal Failure.
Early stage
Early stages= polyuria
Inability to concentrate urine- nocturia
Urinary System Changes with Renal Failure.
Later stage
Later stages= oliguria to anuria
Oliguria = <400 ml/24 hrs.
Anuria= <100 ml/24 hrs.
Amount of urine has nothing to do with quality
Waste product accumulation in spite of amount of urine
Urinary System Changes with Renal Failure.
Final (Uremia) stage
Uremia (raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys), (final stage) occurs when toxins normally sent out in urine end up in the bloodstream. Uremia s/s: Metallic taste in mouth, anorexia, N&V Muscle cramps, fatigue, hiccups Edema, dyspnea, paresthesia's.
Stages of Renal Failure
Stage 1
Stage 1
Kidney damage with normal or increased GFR >90
Asymptomatic normal BUN and creatinine.
Screen for: nephrotoxic meds, glucose control, HTN to reduce progression.
Stages of Renal Failure
Stage 2
Stage 2
Mildly decreased GFR 60-89 ml/min
Asymptomatic possible HTN labs usually WNL
Focus on reduction of risk factors.
Stages of Renal Failure
Stage 3
Stage 3: Renal insufficiency
Moderate GFR decrease 30-59 ml/min
HTN, possible anemia, fatigue, anorexia, slight elevation of BUN & Creatinine. Implement strategies to slow progression.
What is AXotemia?
Azotemia:
is a medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood. It is largely related to insufficient filtering of blood by the kidneys It can lead to uremia if not controlled.
Azotemia: Increased blood levels of nitrogenous waste products
What is Uremia?
Uremia can be translated as “urea in the blood”. Urea is one of the primary components of urine. It can be defined as an excess of amino acid and protein metabolism end products, such as urea and creatinine in the blood that would be normally excreted in the urine.
What is AZotemia?
Azotemia is another word that refers to high levels of urea, but is used primarily when the abnormality can be measured chemically but is not yet so severe as to produce symptoms. Uremia is the pathological manifestations of severe azotemia
Stages of Renal Failure
Stage 4:
Stage 4: Renal Failure=Start Dialysis
Severely decreased GFR 15-29 ml/min
Anemia, edema, hypercalcemia, possible uremia, azotemia with increasing BUN and serum creatinine
Stages of Renal Failure
Stage 5
Stage 5: End Stage Renal Disease (ESRD) Kidney failure with azotemia and overt uremia Multi-system problems Kidney transplant/dialysis. GFR <15 mL/ min
Nephrotoxic Medications
Antibiotics
-Aminoglycosides, Cephalosporins, mycins such as Gent, Tobramycin, Vancomycin, sulfonamides
Diuretics: Lasix (overuse)
NSAIDs
Chemotherapy agents
Magnesium containing antacids & laxatives
Metformin
Lead
RADIOLOGIC CONTRAST DYES
Multisystem effects of ESRD
Fluid and electrolytes
Cardiovascular: atherosclerosis, HTN, pulmonary edema, HF
Hematologic: anemia, impaired platelet function, bleeding risk
Immune system: infection, inflammation, fever
Gastrointestinal: N/V, anorexia, hiccups, peptic ulcers
Neurologic: CNS fatigue, insomnia, diff concentrating
Musculoskeletal: renal osteodystrophy, renal rickets
Endocrine/Metabolic: glucose intolerance
Dermatologic: anemia, retained pigment (pale/yellow), bruising, poor skin turgor
Assessment findings in ESRD
see chart
Nutrition Therapy in ESRD
Primary goal?
Primary goal Decrease HTN Minimize edema Decrease urinary protein losses Slow progression of renal disease.
Nutrition Therapy in ESRD
Diet consists of
Diet consists of Low sodium Low potassium & low phosphorus Moderate protein from complete proteins Avoid high glycemic index carbohydrates Sometimes fluid restrictions Nutritional needs vary depending on degree of kidney function & type of dialysis used (HD vs peritoneal)
Diet Rationales
Low Sodium
Low Sodium
Helps control HTN and edema
Controls weight gain
Na+ intake more limited as disease progresses.
Diet Rationales
Low Potassium- Stage IV& V
Low Potassium- Stage IV& V
Prevention of hyperkalemia (KCL increased in renal failure as GFR decreases).
Varies by urine output
If anuria K more restricted higher risk of hyperkalemia (serum K rises as GFR declines)
Diet Rationales
Low Phosphorus for CKD 3 & 4
Low Phosphorus for CKD 3 & 4
Restricted in hemodialysis because high serum phosphorus contributes to secondary hyperparathyroidism and raises calcium-phosphorus levels in the plasma
Healthy kidneys filter out extra phosphorus.
Diet Rationales
Functions of phosphorus
Functions of phosphorus
Creates energy
Maintains a normal PH balance
Phosphorus added to many canned and bottled drinks.
Rare to have phosphorus deficiencies usually excess in USA
Diet Rationales
Foods
Foods
canned colas, drinks, & other bottled drinks high Phosphorus
Prepared foods read labels for “phos” containing ingredients.
Food high in phosphorus
See PPT
Diet Rationales
High Biologic Value Proteins:
High Biologic Value Proteins: Eggs Meats Poultry Game Fish Soy Dairy products
Diet Rationales
Protein
Body cannot store proteins like it can carbohydrates and fats.
Excess protein is changed into urea by the kidneys.
Increase CHO & fat intake to maintain energy requirements.
Low potassium foods
See PPT
PREVENTION OF CHRONIC RENAL FAILURE
Limit catheter use /use sterile technique when catheter is used
Aggressively treat DM, HTN, Acute Glomerulonephritis, UTI’s
Watch for low UO & BP; report promptly (Prevent ACUTE RENAL FAILURE)
Monitor Nephrotoxic meds carefully
Maintain hydration especially in presence of nephrotoxic meds.
Medications for ESRD
See PPT
Goals of Dialysis in ESRD
Remove waste products & excess fluid
Restore electrolyte and acid base balance in body
HEMODIALYSIS
Blood circulates through Artificial Kidney by dialyzer to:
Remove waste products & excess fluid restoring fluid & electrolyte & acid-base balances.
Manages symptoms does not cure
Performed usually 3 times/week 3-4 h each run
Hemodialysis Access Sites
Can be Permanent or Temporary
Central catheter- temporary
Arteriovenous Fistula (AVF)
Hemodialysis NI
Nursing Care:
Palpate fistula for a Thrill each shift
No B/P or lab draw in affected arm POST SIGN on wall/armband
Monitor for bleeding and s/s infection
New AVF takes 2 wks-4 months to mature in order to accommodate large bore needles.
No lab draws or Iv’s on affected side.
Nursing Care During Hemodialysis
Hold most medications check with RN clinically.
- BP MEDS, WATER SOLUBLE MEDS HELD
- Usually allow Insulin, Tums, protein & lipid bound meds - but check with HD staff. Hypotension common during HD
Monitor patient VS, access site, and machine functioning during treatment
Some patients may be able to eat
Assess for possible complications
Weight before and after dialysis to determine if correct amount fluid removed
Post-Dialysis Care
Vital signs (B/P should decrease after dialysis)
Labs
Fluid status- weight “dry weight” (after dialysis)
Assess for bleeding r/t heparin used during HD
Dialysis disequilibrium syndrome
Dialysis disequilibrium syndrome- results from rapid reduction in electrolytes & other particles.
Rare in today’s HD practices.
Occurs during or after HD.
Causes mental status changes, seizures & coma.
Mild form of disequilibrium syndrome s/s include:
HA, vomiting, nausea
Fatigue, restlessness.
Why? blood-brain barrier causes slow removal of waste products from the brain that cause above symptoms
Peritoneal Dialysis
Exchanges wastes, fluid and electrolytes to occur in the peritoneal cavity.
Slower than HD and more time needed to achieve the same effect.
Use of PD is declining. <10% of dialysis population is using PD.
Silicone catheter surgically placed into abdominal cavity.
Fill, dwell, drain period.
Frequency of PD is determined by physician based on s/s and lab data.
Peritoneal Dialysis
advantages
Advantages
Allows more freedom for pt.
More liberal fluid & nutrient intake allowed
Fluids/solutes removed slower than HD= less risk to unstable patient
Peritoneal Dialysis
disadvantages
Disadvantages
Less effective metabolite elimination
Higher risk of infection- peritonitis= cloudy fluid return during drain. Use aseptic technique with catheter.
Assessment in PD (peritoneal dialysis)
Vital Signs Daily weights Labs Measure and Record Abdominal Girth Monitor clarity of fluid drained –cloudy= infection
Bladder Cancer
risk factors
Risk Factors
Cigarette smoking – primary risk factor
Chronic UTI’s & renal calculi
Exposure to chemicals & dyes in plastic, rubber, spray paint.
Bladder Cancer
Assessment
Diagnosis
Assessment
Painless hematuria 75% of cases
Diagnostic: biopsies most specific to detect cancer.
Bladder Cancer
Treatment
Treatment
Radiation- palliative in nature
Chemotherapy-
Surgery - cystectomy
Bladder Cancer Chemotherapy
Intravesical chemotherapy -Chemotherapy or immune stimulating agents instilled into bladder via urethral catheter.
Bladder Cancer Chemotherapy
NI
Nursing interventions:
bladder emptied prior to installation
patient position changed frequently so solution contacts bladder tissue surface
side effects tend to be more localized – hematuria, urinary frequency/urgency
After dwell time pt. voids. Live virus excreted in urine. Teach clean toilet well, do not share toilet for 24 hrs. after Tx. Wear gloves to clean toilet.
Renal Neoplasms
s/s
S/S:
Often silent dx occurs at advanced stages
Late: gross hematuria, flank pain, palpable mass
Hematuria(microscopic) consistent symptom
Renal Neoplasms
Treatment
Treatment
Nephrectomy – Tx of choice
No chemo drug shows consistent tumor regression
Renal Neoplasms
Risk factors
Risk Factors: Smoking Obesity HTN Exposure to occupational chemicals
Types of UI (urinary incontinence):
Stress: involuntary loss of urine during activities that increase abdominal pressure (cough, sneeze, exercise).
Urge: overactive bladder (OAB). Involuntary loss of urine with strong desire to urinate.
Mixed: combination of stress & urge incontinence.
Overflow: involuntary loss of urine assoc. with overdistention of bladder when bladder has reached capacity.
Functional: leakage of urine caused by factors other than disease of the lower urinary tract.
Bladder Re-training
Measures that stimulate reflex voiding:
Scheduled voiding
Stroking or pinching abdomen or inner thigh, glans penis
Pulling pubic hairs
Tapping SP region
Credes method (manual pressure on the abdomen at the location of the bladder)- caution in spinal cord injury r/t AD
Insert finger into rectum and stretch anal sphincter
Provide privacy.
