Ch. 57, 59, 60 Flashcards
1
Q
major parts of the urinary system (anatomy)
A
- kidneys
- ureters
- urinary bladder
- urethra
2
Q
renal capsule
A
- outside part of the kidney
- surrounds the kidney (encapsulates the kidney)
3
Q
hilum
A
- part where kidney bends in
- where the renal artery, renal vein and ureter all enter the kidney
4
Q
renal cortex
A
- outer most layer inside of the kidney
5
Q
medulla
A
- deeper into kidney
- loop of henle in here
6
Q
renal pelvis
A
- inner most, core of the kidney
7
Q
anatomy of a nephron
A
- afferent arteriole
- glomerulus
- PCT
- loop of henle
- DCT
- collecting duct
1million-1.5million nephrons per kidney
kidney damage = nephron damage
8
Q
afferent arteriole
A
where blood first enters the nephron from the artery
9
Q
glomerulus
A
- blob tangle of capillaries and arteries
- lots of surface area
- where filtration happens
- contains the glomerular capsule
- filtration membrane- only things that can get through water, small solutes; protein, RBCs too big and stay in the blood
“the washing washine”
10
Q
PCT
A
proximal convoluted tubule
- solutes and wastes enter here from the glomerulus
11
Q
loop of henle
A
connects the PCT and DCT
12
Q
DCT
A
distal convoluted tubule
13
Q
collecting duct
A
where waste products sit and wait until they are excreted via urine
14
Q
glomerular filtration rate (GFR)
A
a measure of how well your kidneys are functioning
- the rate at which blood passes through the glomerulus (the filter) in mL/min
healthy kidney filters 90mL/min or more: normal GFR is > 90
15
Q
tubular reabsorption vs tubular secretion
A
at different stages of filtration, there are parts of the tubular system that reabsorb or secrete different electrolytes
- this is why there are different types of diuretics that work on different electrolytes (ie loop vs potassium-sparing diuretics)
16
Q
renin cells
A
cells in the kidney that regulate blood pressure, fluid and electrolyte balance, and development of kidney vasculature
17
Q
renal/urinary system age-related changes
A
- reduced renal blood flow causing kidney loss of cortical tissue by 80 years of age (kidney size shrinks)
- thickened glomerular and tubular basement membranes, reducing filtrating ability
- decreased tubule length (not as much surface area)
- decreased glomerular filtration rate (GFR) (not as much bang for buck as pt ages)
- nocturnal polyuria and risk for dehydration (urinate often, dilute watery urine, leads to dehydration in elderly)
18
Q
assessment of the urinary system includes
A
- family hx and genetic assessment (ie polycystic kidney disease)
- demographic data and personal hx
- gender: biological male vs biological female (female has shorter urethra = higher infection risk)
- diet hx
- socioeconomic status (not able to seek care, eduction limits, exposure to noxious chemicals, HTN uncontrolled)
- current health problems
- physical evaluation
19
Q
what kinds of blood tests are used for urinary system d/os?
A
- serum creatinine (Cr)
- blood urea nitrogen (BUN)
- creatinine clearance
- BUN/Cr ratio
20
Q
normal range serum creatinine (male and female) and what is it?
A
male: 0.6-1.2
female: 0.5-1.1
- byproduct of muscle breakdown (should be pretty stable all the time)
- nothing increases serum Cr level other than kidney disease (or false elevation from dehydration)
- Cr is cleared ONLY by the kidneys
- blood test or urine test (creatinine clearance test)
21
Q
normal range blood urea nitrogen (BUN) (by age) and what is it?
A
<60 yo: 10-20 mg/dl
60-90 yo: 8-23 mg/dl
- protein (by food; ingested protein) breakdown by the liver; BUN is byproduct of protein
22
Q
normal range Bun/Cr ratio
A
12:1 to 20:1
23
Q
what does a Bun/Cr ratio over 20:1 mean? ie 35:1
A
if ratio is over 20:1, ie 35:1, then usually just the BUN is high and Cr is falsely elevated due to hemoconcentration
ie BUN 100, Cr 4 –> ratio 25:1
24
Q
what does it mean if the BUN/Cr ratio is within normal range, BUT the BUN and Cr alone are both high?
A
usually indicates renal damage/kidney disease because Cr is elevated
ie BUN 50, Cr 4 –> ratio 12.5:1
25
dx tests for renal d/os
- bedside sonography/bladder scans: to look for residual in the bladder before we catheter, feeling of fullness, retention
- CT scan: suspicion for hydronephrosis or renal calculi (stone)
- kidney, ureter, and bladder x-rays (KUB x-ray)
- renal ultrasound: look at blood flow and structure of the kidneys
26
what is a renal arteriography (angiography)?
- injection of radiopaque dye into renal arteries
- lights up vessels under x-ray
- assessment for bleeding in the renal arteries
- shows aneurysm, malformation in arteries bring blood to the kidney
27
what are the nurse responsibilities for a renal arteriography (angiography)?
- possible bowel prep
- light meal evening before, then NPO
- monitor VS
28
blood supply
- comes in from the renal artery
- comes in the afferent arteriole (from the artery)
- into the glomerulus
- exists through the efferent artiole
- waste products from glomerulus go into the PCT
- wastes into loop of henle
- then into DCT
- collects in the collecting duct, which eventually leads to exiting the body via urine
29
what could a high BUN mean?
- dehydration
- hemoconcentration
- extra muscle work (injured tissue, working out a lot)
- injuries
- GI bleeding
30
glomerulonephritis
- collection of immune complexes in the glomeruli
- affects the "washing machine" glomerulus
- acute vs chronic
31
what causes glomerulonephritis?
- exposure to bacteria, viruses, drugs, toxins
- antigen-antibody complex from recent strep infection
32
acute glomerulonephritis usually occurs after __
usually follows an infection/recent illness
- URI/Skin/strep 10 days before
33
acute glomerulonephritis patient assessment
- connection w/ sore throat (or recent illness)
- proteinuria
34
s/sx of acute glomerulonephritis
- HA
- lethargic
- increased BP (HTN)
- facial/periorbital edema*
- low grade fever
- weight gain from edema
- cola colored urine (bc hematuria)
35
labs for glomerulonephritis
- proteinuria (protein in urine)
- hematuria (blood in urine)
- oliguria (decreased UO)
- dysuria (no UO)
- low albumin
- low GFR
- increase BUN/Cr
36
dx test for glomerulonephritis
kidney biopsy
37
glomerulonephritis: antigen-antibody complex in glomeruli causes ___
- inflammation (think facial edema)
- decreased GFR
38
nursing interventions for glomerulonephritis
- manage infection- ABT
- steroids- inflammation
- immunosuppressants
- prevent complications
- dialysis- short-term
- plasmapheresis
- patient education- take meds as prescribed, daily weight, BP
39
chronic glomerulonephritis
- develops over years to decades
- exact cause is unknown
- always leads to ESRD
- not reversible
- young patients can get this, not just elderly--> transplant
40
s/sx of chronic glomerulonephritis
- mild proteinuria
- hematuria
- HTN
- fatigue
- occasional edema
41
nephrosclerosis is
thickening in the nephron blood vessels, resulting of the vessel lumen, narrow nephron vessels
42
nephrosclerosis occurs with
- all types of HTN
- atherosclerosis
- DM
43
nursing interventions for nephrosclerosis*
- control high BP (HTN)
- manage sugars- blood glucose for DM pt
- preserve kidney function
44
renovascular disease is
processes affecting renal arteries
- something wrong with vessel so can't get blood to kidney
- could be blockage
- may severely narrow lumen
- profoundly reduces blood flow to the kidney tissue
- causes ischemia and atrophy of renal tissue
45
renovascular disease assessment: key sx
new onset HTN
46
priority care goal for renovascular disease
manage BP (HTN)
47
nursing interventions for renovascular disease
- stent placement
- renal artery bypass
48
diabetic nephropathy is
a MICROvascular complication of either type 1 or type 2 DM
- glucose is hard to process by the kidneys, so a patient with uncontrolled diabetes is hurting their kidneys, predisposing them to kidney injury
think chronic hyperglycemia = kidney damage
49
first sx of diabetic nephropathy is
persistent albuminuria (albumin (protein) in the urine)*
50
what should the patient with diabetic nephropathy avoid?
- nephrotoxic agents and dehydration
- hold metformin before CT of kidney
51
priority goals for diabetic nephropathy
prevention of ESKD (end-stage kidney disease)
52
acute renal failure/acute kidney injury: patho
- losing perfusion to the kidney is the #1 cause of kidney failure
- think acute: something just happened to hurt the kidney (acute = sudden onset)
- rapid decrease in renal function leads to collection of metabolic wastes in the body
- oliguria (<400mL/day) or anuria (none)
53
types of acute renal failure
- prerenal: perfusion (hypotension, shock)
- intrarenal: kidney issue (embolus in vessels, nephrotoxic drugs, allergic or autoimmune condition
- postrenal: obstruction/blockage (stone, tumor, stricture)
54
prerenal azotemia
back up of waste products in the blood without symptoms that occurs with AKI (prerenal AKI)
55
causes of acute renal failure
- hypovolemic shock: #1 cause
- heart failure: d/t lack of perfusion (20% of hospitalized patients and 60% of ICU get AKI)
56
phases of acute renal failure
- onset
- oliguria
- diuretic
- recovery
57
phases of rapid decrease in renal function lead to
the collection of metabolic wastes in the body
58
is acute renal failure reversible?
possibly with prompt intervention
59
acute kidney injury: health promotion
- teach healthy adults to drink 2-3L of water daily
- avoid exposure to nephrotoxic drugs (no advil, NSAIDs)
60
AKI assessment: history
- health promotion
- diabetes?
- have a CT recently? the dye is nephrotoxic
- nephrotoxic substances
- anticipate AKI after hypotension/shock (ID situations that precipitate this)
61
s/sx of AKI: prerenal
hypotensive shock pt
- hypotension
- shock
- sick pt presentation
- edematous because hanging onto fluids + not excreting urine (listen to lungs- crackles)
62
s/sx of AKI: intrarenal
pt may act fine, feel fine, but lab values are off
63
what electrolyte changes are expected with AKI?
- sodium: can go high or low
- potassium: hyperkalemic (b/c not excreting urine; pt will be in metabolic acidosis)
- phosphorus
64
management for acute kidney injury
- diuretics: lasix
- fluid challenge: giving pt IVF NS to try to wake the kidney up, close monitoring because pt is already in fluid overload
- treat electrolyte imbalances
65
treatment for AKI
- avoid hypotension/maintain fluid balance
- diet therapy:
-low sodium
-low potassium (avoid bananas, dried fruits, check salt replacements)
-low phosphorus (avoid soda, bottle ice teas)
- dialysis: if diuretics and fluid challenge don't work; need to dialyze pretty quickly (use a permacath, IV in the chest)
66
dialysis therapies for AKI
- hemodialysis
- peritoneal dialysis
- temporary dialysis for acute kidney injury
67
post-hospital care for pt with AKI
- if renal failure resolving, follow-up care may be required
- there may be permanent renal damage and the need for chronic dialysis or even transplant
- temporary dialysis is appropriate for some patients
68
chronic renal failure/chronic kidney disease
- progressive, irreversible kidney injury
69
azotemia is
collection of nitrogenous wastes in the blood without symptoms
- seen in acute and chronic kidney injury
70
uremia is
azotemia (nitrogenous wastes in the blood) with clinical symptoms
71
uremic syndrome is
systemic clinical and lab manifestations of end-stage renal disease (ESRD)
72
stages of CKD
five stages based on GFR category
- stage 1
- stage 2
- stage 3
- stage 4
- stage 5
73
CKD etiology and genetic risk
- more than 100 different disease processes can result in progressive loss of kidney function
- 2 main causes: HTN & DM
74
Two main causes of CKD leading to dialysis or kidney transplantation:
- HTN
- DM
75
CKD incidence and prevalence
- about 15% of adults in the US are estimated to have CKD
- most adults that have CKD do not know that they have it
76
CKD: stage 1
- AT RISK for renal failure: abnormal urine findings, structural abnormalities, genetic risk, something in the PMH
- NORMAL function: GFR > 90
- no symptoms
- interventions: screen and manage risk factors to decrease risk- manage HTN, DM, drink 2L/day, don't pop NSAIDs like candy
77
CKD: stage 2
- Unaffected nephrons overwork
- GFR 60-89
- ? Presence of albuminuria: could or could not have it
- No or mild accumulation of metabolic wastes
- No change in BUN/Cr b/c kidneys are compensating well enough
- May have increase in dilute urine (patient is peeing more frequently but the patient is dehydrated b/c kidneys are not concentrating the urine)
- no symptoms really
- Interventions: Focus on risk factors -> monitor for dehydration- hydration
78
CKD: stage 3
- Moderate CKD
- GFR – 30-59
- Azotemia (nitrogenous wastes in blood)
- interventions: Implement strategies to slow disease progression: Restrict fluids (not making nice urine), proteins (hard on the kidneys: BUN) and electrolytes (K and Na)
79
CKD: stage 4
- aka severe CKD
- GFR- 15-29
- Accumulation of metabolic wastes
- Decreased urine output
- Increase in BUN, Cr (b/c kidneys not working), Uric Acid (risk of gout, kidney stones), Phosphate
- impaired fluid and electrolytes and Acid/Base balance (metabolic acidosis)
- Interventions: manage complications; progresses to ESRD; need kidney replacement therapy: talk about shunt made for dialysis
80
CKD: stage 5
- aka ESRD
- GFR < 15
- Excessive amounts of metabolic waste
- Unable to maintain homeostasis
- Requires renal replacement therapy
- shunt made for dialysis
81
end-stage renal disease (ESRD) s/sx
- neuro weakness, fatigue, confusion
- increased BP, pitting edema, periorbital edema, increased CVP, pericarditis
- SOB, depressed cough, thick sputum
- anemia (kidneys are not making the e poetin needed by bone marrow to make RBCs)
- withdrawn, behavioral changes
- dry flaky skin, pruritis, ecchymosis, purpura
- muscle cramps, renal osteodystrophy, bone pain
- ammonia odor to breath, metallic taste, mouth/gum ulcers, anorexia, N/V
82
CRF/CKD affects
- GI: anorexia, N/V
- kidney
- metabolic: urea and creatinine, acid/base balance
- electrolytes: sodium, potassium
- calcium and phosphorus
- hematologic: decreased epoetin alpha = anemia
- HTN
- hyperlipidemia
- congestive heart failure
- uremic pericarditis
83
CKD patient problems
- Fluid overload due to the inability of diseased kidneys to maintain body fluid balance
- Decreased cardiac function due to reduced stroke volume, dysrhythmias, fluid overload, and increased peripheral vascular resistance
- Weight loss due to inability to ingest, digest, or absorb food and nutrients as a result of physiologic factors
- Potential for injury due to effects of kidney disease on bone density, blood clotting, and drug elimination
- Potential for psychosocial compromise due to chronic, debilitating, life alerting illness
- emotional state
84
interventions for imbalanced nutrition r/t CKD
- diet evaluation of
-Protein
-Fluids
-Potassium
-Sodium
-Phosphorus
- vitamin supplements
85
interventions for excess fluid volume r/t CKD
- Monitor client’s intake and output
- Promote fluid balance
- Assess for manifestations of volume excess: edema, lung sounds: crackles
- Drug therapy: lasix
86
interventions for risk of infection r/t CKD
- Meticulous and preventive skin care
- Inspection of vascular access site for dialysis
- fever, redness at site, drainage
- rigid board-like abdomen for peritonitis
- Monitoring of vital signs for manifestations of infection
87
interventions for fatigue r/t CKD
- Assess for vitamin deficiency, anemia, and buildup of urea
- Administer vitamin and mineral supplements
- Administer erythropoietin therapy for bone marrow production
- Give iron supplements as needed
88
interventions for anxiety r/t CKD
- Health care team involvement
- Client and family education
- Continuity of care
- Encouragement of client to ask questions and discuss fears about the diagnosis of renal failure
89
hemodialysis
- blood
- Client selection
- Dialysis settings
- Works using passive transfer of toxins by diffusion
- Anticoagulation needed, usually heparin treatment
90
vascular access for hemodialysis
- AV fistula: Arteriovenous fistula, or arteriovenous graft for long-term permanent access: connecting an artery and vein to be used after healed for hemodialysis (will feel thrill with AV shunt)
- Hemodialysis catheter, dual or triple lumen, or arteriovenous shunt for temporary access
91
precautions for vascular access/hemodialysis
no BP on shunt side
92
complications of vascular access/hemodialysis
- infection
- cardiac arrest (b/c messing around with electrolytes and pressures: hyperkalemia)
- bleeding at the site
93
nursing implications for vascular access/hemodialysis
- monitor s/ of infections
- monitor bleeding
- make sure patient is going to dialysis appts consistently
94
temporary catheter
drop it in and its good to go
- can be used for acute and chronic
- used for chronic while AV fistula/shunt is healing
95
hemodialysis circuit
blood comes out of patient and goes through dialysis filter, then put filtered blood back into patient
96
hemodialysis nursing care: pre-dialysis
- medication administration: might get heparin to thin the blood for dialysis
- hold meds before dialysis, get washed out
97
hemodialysis nursing care: post-dialysis
- monitor for complications: hypotension, HA, N/V, malaise, dizziness, muscle cramps
- Monitor vital signs and weight
- Avoid invasive procedures 4-6 hours after dialysis.
- Continually monitor for hemorrhage
98
complications of hemodialysis
- Dialysis disequilibrium syndrome: dizzy, nauseated
- Infectious disease: HIV
- Hepatitis B and C: blood exposure
99
peritoneal dialysis is
Procedure involves siliconized rubber catheter placed into the abdominal cavity for infusion of dialysate.
100
types of peritoneal dialysis
- Continuous ambulatory peritoneal
- Automated
- Continuous-cycle peritoneal
101
complications of peritoneal dialysis
- Peritonitis* - sx: Pain, fever, rigid board-like abdomen
- Exit site and tunnel infections*
- Poor dialysate flow: less than what was put in
- Dialysate leakage
102
nursing care during peritoneal dialysis
- Before treating, evaluate baseline vital signs, weight, and laboratory tests.
- Continually monitor the client for respiratory distress, pain, and discomfort.
- heating pad to keep dialysate solution warm
- STERILE procedure by nursing, patients usually do this clean at home
- Monitor prescribed dwell time and initiate outflow.
- Observe the outflow amount and pattern of fluid: want clear fluid outflow.
103
kidney transplant: candidate selection criteria
- Advanced kidney disease
- Reasonable life expectancy
- Medically and surgically fit for procedure
- In U.S. – waiting list when GFR < 20 mL/min
104
kidney transplant: types of donors
- Living donors (highest rate of graft survival)
- Non-heart-beating donors (fresh dead)
- Cadaveric donors (has been dead)
105
type of peritoneal dialysis: Continuous ambulatory peritoneal
pt hooks themself up, then unhooks themself from it
- fill up belly with bag through gravity
- dwell for several hours, wear loose clothing
- after dwell period, fluid empties out the belly by gravity (pt can move around: side to side, lean forward back, to make sure that outflow is equal or more than what was put in)
- fluid coming out should be clear
106
type of peritoneal dialysis: Automated
machine does it
- do it at night
- clear fluid output
- make sure that outflow is equal or more than what was put in
107
type of peritoneal dialysis: Continuous-cycle peritoneal
machine does it
- do it at night
- clear fluid output
- make sure that outflow is equal or more than what was put in
108
critical Cr level is
>1.3 is a sick kidney
109
drug therapy for chronic kidney injury
- Vitamins and minerals (for pt w/ nutrition concerns)
-Folic Acid, vit D, nephro-bite
- Biologic response modifiers
-Epoetin alfa: for RBC production, anemia
- Phosphate binders
-Sevelamer: pulls phosphate from body and binds it to get rid of it
- Stool softeners and laxatives (for peritoneal dialysis; prevent constipation)
- Calcium channel blockers: to get BP down
- diuretics: lasix
- monitor fluids; fluid challenge
- Digoxin (not a great drug- was used, now moving away)
110
poor diet choices for pt w/ kidney injury
- bananas
- tomatoes
- greens
- nuts
- sodas
- bottled teas
- ice cream
- yogurt
- dairy
- oranges
111
what could a low BUN indicate?
- too much hydration
- malnourished
