Exam 3: Urinary and Kidney 2 Flashcards
What is less common upper or lower UTIs
Upper UTIs
Upper UTI
Infection above the bladder
It occurs from upward spread of bacteria - like if a stricture or stone is not allowing bacteria in the bladder to empty and it then spreads into the ureters and kidneys
Could also be from systemic infections like those in the blood that reach the kidnes - and systemic infection can lead to abscesses (Ex: Tb can lead to abscess in the kidney)
What are upper UTIs usually due to
ascension of pathogenic bacteria from a bladder infection, static urine d/t obstruction, or systemic infections that result in abscesses
Upper UTIs include what
acute or chronic pyelonephritis (inflammation of renal pelvis)
Interstitial nephritis (inflammation of the kidney
Kidney abscesses
Pyelonephritis
Can be acute or chronic inflammation/infection of the renal pelvis
Acute Pyelonephritis s/s
chills
fever
leukocytosis
bacteriuria
pyuria
low back pain
flank pain
NV
HA
malaise
painful urination
Chronic Pyelonephritis s/s
Usually NO symptoms of infection unless an acute exacerbation occurs
Noticeable signs may include fatigue, HA, poor appetite, polyuria, excessive thirst and weght loss
When is chronic pyelonephritis diagnosed
often incidentally when being evaluated for HTN
What to look for on assessment for chronic pyelonephritis
poor urine concentrating ability
pyuria
azotemia
proteinuria
anemia
acidosis
Azotemia
nitrogenous waste in urine
When do we usually see s/s of pyelonephritis
usually only in acute exacerbations not so much chronic
How is the extent of chronic pyelonephritis checked
usually by IV urogram and lab work (lab work includes creatinine clearance, BUN,, and creatinine levels)
What is an important vital to check whenver a kidney issue is expected
Blood pressure - it is an important function of the kidneys
Common Nursing Dx for pyelnoephritis
1 PAIN
Infection
Alterations in voiding patterns
Knowledge deficits r/t lack of understanding of tests and procedures
Goals with Pyelonephritis
Pain reduction
Medication compliance
proper hygiene
Patient education on pyelonephritis is focused on ___.
prevention
Interventions for Pyelonephritis
Monitor VS, I&O, and Weight
Encourage fluids up to 3000 mL a day
Encourage adequate rest
Instruct on high calorie low protein diet
warm moist compresses to flank area
encourage warm baths (this one can cause infection though)
administer antibiotics analgesics antipyretics urinary antseptics and antiemetics as prescribed
monitor for signs of renal failure
education
How much fluid should be given a day to dilute urine in pyelonephritis
3-4 L / 3000mL-4000mL
What is an important sign of concerning I&O changes
increases or decreases in weight
Education topics for pyelonephritis
prevent further infection by adequate fluid consumption and regular bladder emptying, perineal hygiene and taking meds as prescribed
keep follow up appointments
Chronic Kidney Disease
Umbrella term to describe kidney damage or a decrease in the glomerular filtration rate for 3+ months
Untreated CKD can result in…
ESRD and a need for kidney transplant or dialysis
Risk Factors for CKD
Primary Cause: Diabetes
HTN
CV Disease
Obesity
What is different between Acute Kidney Injury and CKD
Acute Kidney injury is one time and reversible if you ID and treat promptly before it damages the function of the kidneys
CKD is 3+ months of this and the kidneys may progress to CRF
Causes of Acute Kidney Injury
hypovolemia
hypotension (decreased blood flow to kidneys)
Reduced cardiac output and heart failure
obstruction of kidney or lower urinary tract
obstruction of renal arteries or veins
may result in CKD but does not always
Causes fo CKD
diabetes
HTN!!!!!!!!
chronic glomerulonephritis
pyelo/other infections
obstruction of urinary tract if not treated
hereditary lesions
vascular disorders
medications/toxic agents
CKD may lead to need for…
Dialysis or Kidney Transplant if enough damage occurs
Stages of Chronic Renal Failure (CRF)
Stage 1: Slight Damage
- Mild Decrease in Fxn
- Moderate Decrease
- Severe Decrease
- ESRD
What is the GFR (Glomerular Filtration Rate) like at all 5 stages of CRF
- GFR >90
- GFR 60-89
- GFR 30-59
- GFR 15-29
- GFR <15
Things to Assess with CKD
fluid status
ID potential sources of imbalance
assess nutritional status
knowledge of their nutrition and I&Os
assess potential complications like HTN, anemia, weight change, etc
Nursing Dx for CKD
Excess fluid volume
Imbalanced nutrition
Deficient knowledge
Risk for situational low self esteem
Goals for CKD
maintain ideal body weight and dont have excess fluid
work with their preferences for an appropriate diet
adequate intake
Diet is very important to CKD but…
can be very restrictive - especially regarding preferences
Gerontologic Considerations for CKD
Risks like aging, HTN, atherosclerosis, HF, DM, and cancer predispose elders to kidney disease
Polypharmacy and changes in renal bloodflow, decreased GFR, and decreased renal clearance are also assoc with changes in renal function
What is the double sided issues with the gerontologic risk factors for renal disease
while they increase CKD incidence they also mask th s/s of it and make it harder to diagnose
Why do diuretics need to be monitored carefully when given to elderly
We need to assess for dehydration that can further compromise renal function and contribute further to renal failure
Conservative Gerontological management of CKD includes
nutritional therapy
fluid control
phosphate binders
Renal Replacement Therapy
Dialysis: Hemodialysis and Peritoneal Dialysis
Replacement therapy is needed when the kidneys cannot remove waste products - the waste that is usually excreted is urea
Goal of Hemodialysis
to remove toxic nitrogenous waste and water from the blood
clean and remove blood then return it to the system
What is vascular access for hemodialysis like
double lumen, large bore catheter into a large vein OR AV fistula or AV graft
AV Fistula/Graft
permanent joinings of artery and vein that takes 3 mo to heal - for more permanent access for hemodialysis
When there is a hemodialysis vascular access…
never take BP on that side and assess for bruits or thrills
Nursing Management Considerations for Hemodialysis
VS (esp. BP) and hemodynamic Status
Protecting Vascular access device
Palpating for thrills
Observe for infection
Dressing changes
Adjusting IV rate and strict I&O
Assess for complications
Administer blood transfusions during dialysis
Education
pain management
psychological support
Ways to protect vascular access
avoid BPs (place colorful band to indicate this), tight dressings, restraints, or jewelry over the device
How often should a thrill be checked for over the access for dialysis
every 8 hours - if absent there may be a blockage or clot
What complications and s/s should be monitored for when a patient is on hemodialysis
infection at site: redness, draining, fever, chills, swelling
Fluid overload
HF
pulmonary edema secondary to fluid build up
substernal chest pain, low grade fever, pericardial friction rub –> All 3 indicate pericarditis
Why is it so important to use proper dressing change technique when dealing with hemodialysis patients
because renal patients are more prone to infection
Why does the IV rate for hemodialysis need to be as slow as possible
because dialysis patients cannot secrete water - use a pump
If a patient on hemodialysis progresses to pericardial effusion what can be telling of this
the friction rub will disappear and heart sounds will be distant and pulsus paradoxus is noticeably worse
Why are blood transfusions administered during dialysis
so excess K+ can be removed
Things to education Hemodialysis patients on
dietary intake to prevent complications of hypoalbuminemia and hyperkalemia
infection prevention
proper med complianace
proper care of the catheter site
proper nutritional choices
When is peritoneal dialysis appropriate
for patients who cannot tolerate hemodialysis or have severe HTN, HF, and pulmonary edema that does not respond to hemodialysis
may be tx of choice for those unwilling or unable to go to hemodialysis
Goal fo Hemodialysis
remove toxxi substances and metabolic wastes
reestablish normal F&E balance
Peritoneal Dialysis Procedure
sterile dialysate is introduced into the peritoneal cavity through an abdominal catheter at intervals
waste products move from an area of higher concentration (blood) to an area of lower concentration (dialysate) through a semi permeable membrane (peritoneum)
How much longer is peritoneal dialysis
pretty continuous - does what hemodialysis does in 6-8 hours over 36-48 hours
Types of Peritoneal Dialysis
Acute Intermittent Peritoneal Dialysis
Continuous Ambulatory Peritoneal Dialysis
Continuous Cyclic Peritoneal Dialysis
Acute Intermittent Peritoneal Dialysis
A nurse warms, spikes, and hangs each container of dialysate
Requires strict asepsis
If dialysate does not drain right, nurse will facilitate draining by turning patient from side to side or raising the head of the bed - NEVER push the catheter further into the peritoneal cavity
Common routine for acute intermittent peritoneal dialysis
hourly exchanges that involve 10 minute infusion, 30 minute dwell time and 20 minute drain time
Impotant assessments to be done with acute intermittent peritoneal dialysis
I&O
VS
Weight
Patient status
Skin turgor and mucous membranes to evaluate fluid status
presence of edema check
Continuous Ambulatory Dialysis (CAP)
2nd most common form
performed at home 4-5 times a day every day
Longer dwell time –> better results
managed by the patient or a trained caregiver
Continuous Cyclic Peritoneal Dialysis
uses a cycler machine and combines overnight intermitted PD with a prolonged dwell time during the day
lower infection rates since fewer bag changes and tubing disconnections occur
greater freedom to work
May need home visits by nurse or f/u calls or visits to outpatient settings to make sure dialysate is ok and BP is monitored carefully
Renal Calculi Cause what pain
RENAL COLIC - originating in lumbar region radiating around the side and down toward the testicle in mean and to the bladder in women
Ureteral Calculi cause what pain
UTERAL COLIC radiates toward the genitalia and thigh
s/s of Urinary Stone Disease
renal or ureteral colic
sharp severe sudden onset pain
dull aching kidneys
NV, pallor, diaphoresis during acute pain
urinary frequency with alternating retention
Signs of a UTI during Urinary Stone Disease
low grade fever
RBCs and WBCs and Bacteria in Urinalysis
Hematuria
Nursing Dx for Urinary Stone Disease
Pain - #1 until cause is eliminated
Risk for INfection
risk for inadequate renal function
Nutrition, risk for…
Patient specific dx
Nursing Goals with Urinary Stone Disease
relieve pain of renal colic
eradicate stone
determine stone type
prevent nephron destruction
control infection
relieve obstruction
Nursing interventions for Urinary Stone Disease
Monitor VS, I&O
Assess fever, chills, infection and Monitor for NVD
Force fluids to facilitate stone passage and prevent infection
Strain all urine and send stones for lab analysis
Provide warm baths and heat to flank area
Administer analgesics regularly to relieve pain and assess response to pain meds
Relaxation techniques to assist pain relief
Diet education based on stone composition
Maintain urinary pH depending on stone type
Turn and reposition
prep for surgeyr if needed
How many fluids sould be forced a day with urinary stones
3000 mL/ 3 L
What is the biggest concern with urinary stone disease regarding nursing dx
The pain
it can be so excruciating nothing seems to relieve it
If a patient has an Alkalytic Stone/Urine what diet should we discuss with them?
Acid Ash Diet
If a patient has an Acidic Stone/Urine what diet should we discuss with them?
Alkaline Ash Diet
Acid Ash Diet
Drops pH
Cranberries
Plums
Grapes
Prunes
tomatoes
Eggs
Cheese
Whole Grain
Meat and Poultry
Alkaline Ash Diet
Raises pH
Legumes
Milk and Milk Product
Green Vegis
rhubarb
Calcium Stones
formed from high levels of calcium so avoid high calcium foods
What is the confusing recommendation regarding calcium stones
new research says avoiding calcium can be bad due to low bone density and osteoporosis and may not really change stone results much so its best to have a little calcium in the diet rather than non
High Calcium Foods
Milk and other dairy products
beans
lentils
dried fruits
flour
chocolate
cocoa
canned and smoked fish (NOT TUNA)
High Oxalate Foods to avoid when you have an oxalate stone
asparagus
beets
celery
cabbage
nuts
tea
fruits
tomatoes
green beans
chocolate
beer
colar
dark green leafy vegis
High Purine Foods to avoid when you have a purine stone (uracid stone)
organ meets
sardines
herring
venison
goose
What can cause increases in calcium and uric acid and lead to stones that you should discuss with the patient about decreasing
high protein and sodium diets
Cystoscopy
Surgical management for stones in the bladder or lower ureter
1-2 catheters are inserted past the stone and mechanically guide it down
NO INCISIONS
What occurs after the cystoscopy removes the stone
the catheters stay in place for 24 hours to drain urine trapped proximal to the stone and dilate the ureter
and continuous chem irrigation is used to dissolve the stone
Cystoscopy used to be the major mode of removing stones until…
lithotropsy
Medical/Surgical procedures for Upper Ureteral Stones
ureteroscopy
ESWL
electrohydraulic lithotrpsy
Stones that are how big usually are easier to pass
6 mm or less
Medical/Surgical Procedures for Renal Stones
endourologic - pecutaneous nephrostomy
nephrolithotomy
nephrectomy
Why is forcing fluids not going to help with ureteral stones and higher
because there is not enoguh peristalsis occurring for it to pass
Nephrostomy
A tube is placed to dilateand allow the stone and urine to come through
Nephrolithotomy
Make incision and remove calculus/stone
Nephrectomy
removal of a kidney
ESWL
Extracorporeal Shock Wave Lithotripsy
Non invasive method of stone removal where a shock wave breaks up the stone to pass it
Usually for non passable upper urinary stones
Pre Procedure ESWL Care
NPO for 8 hours prior to procedure
A laxative may be prescribed
Post Procedure ESWL care
monitor VS, I&O, bleeding, for pain and urinary obstruction
Instruct to increase fluid intake to wash out stone fragments
strain the urine
inform client that ambulation is important (get them up and walking)
ESWL Management
Assess and manage foley cath if needed
Assess nephrostomy tube (may be placed 1-5 days for chemical irrigation)
Encourage 3-4 L of fluid a day following procedure
instruct client to monitor for complications of infection, hemorrhage, and fluid extravasation into retroperitoneal cavity
Ureterolithotomy
Open surgical procedure performed if lithotripsy/ESWL is ineffective and stone is in the ureter or higher
Ureter incision occurs through the lower abdomen or flank incision to remove the stone
What things are likely put inplace following ureterolithotomy
penrose drain
ureteral stent
indwelling bladder catheter likely
3 Options of Ureterolithotomy
Nephrolithotomy
Pyelolithotomy
Nephrectomy
Nephrolithotomy
Large flank incision made into the kidney to remove the stone from the renal calyx
may need a nephrostomy tube and indwelling catheter after
tube will need aspetic tecnique or pyelnephritis can occur
Pyelolithotomy
Large flank incision into kidney to remove stones from the renal pelvis
penrose drain and indwelling catheter
When is a partial or total nephrectomy done
for extensive kidney damage, renal infection, or severe obstruction and to prevent stone recurrence
What is postoperative care of a partial or total nephrectomy like
Plan of care is based on incision location and type of drainage tubes (penrose drains lg amounts of urine - the tube is connected to a bag to collect urine)
Protect skin from urinary damage (ostomy pouch over penrose drain to protect it if excessive urinary drainage)
Monitor nephrostomy tube (attached to drainage bag for free flow of urine) and folet with strict I&O
If there is urethral cathters in place after a nephrectomy…
NEVER IRRIGATE THEM - they are for draining urine
We can irrigate the nephrostomy tube if there is an order, but we never irriagate these
What are important nursing interventions for any open procedure
maintaining airway clearance and breahting
relieving pain - heat, analgesia
promoting urinary elimination - neph tube
Important interventions/care post nephrostomy
(percutaneous or surgical)
bleeding concerns
obstruction concerns
patency of nephrostomy tube concerns
After a nephrostomy it is important to monitor and document what
every I&O from each tube separately
Never do what to a nephrostomy tube
never ever clamp the tube
Urinary Diversion
a surgical procedure that diverst urine from the bladder into an exit site
Reasons for Doing a Urinary Diversion
Bladder cancer or other pelvic malignancies
birth defects
strictures
neurogenic bladder
chronic infection/intractable cystitis
What is the last resort for incontinence
urinary diversion
What are the3 types of urinary diversion
Indiana Pouch
Kock Pouch
Ureterosigmoidostomy
Indiana Pouch
Type of continent urinary diversion
For patients whose bladder was removed or no longer functions
It is made from the terminal ileum and part of the cecum
One way flush valve that has a catheter drain it every 4-6 hours in order to empty it
Kock Pouch
Similar to indiana, but has a nipple like valve/stoma - the end of the small intestine is connected to the outside
You need a bowel prep and oral antibiotics before doing this
When is a kock pouch contraindicated
IBD - Irritable bowel disease
Ureterosigmoidostomy
Continent urinary diversion
ureters attached to sigmoid colon - NOT a continent ostomy
products leave rectum
permanent ostomy and is non reversible
What does it mean that uretersigmoidostomy is NOT a continent ostomy
it means there is always something draining from it - and it is the consistency of watery diarrhea
With this ostomy it allows urine to flow through the colon and out of the rectum - voiding goes through the rectum
Kidney Transplantation
implanation of human kidney from compatible donor if recipient has irreversible kidney failure
How does a kidney transplant cost compared to dialysis
it is 1/3 the cost of dialysis
What must be done for life following a kidney transplantation
immunosuppressive medications - must be taken for life - but has risks
Nursing Dx for Kidney Trnasplantation
Ineffective airway clearance/breathing pattern
acute pain/fear/anxiety
Impaired urinary elimination
Risk for fluid imbalance
Post Op Assessments for Kidney Transplant
Assess pain. fluids, electrolytes
Monitor potential for hemorrhage and shock, abdominal assessment and paralytic ileus
MOnitor I&O and hemorrhage shock risk and distention and pneumonia
Have in semi fowler and monitor
Post Op Kidney Transplant Interventions
Place in semi fowlers position
Monitor patency of Foley cath and gross hematuria and clots, (not expected) –> Notify physician if this occurs
Assess urine characteristic (Starts pink and bloody but gradually returns to normal wihtin days to weeks)
If 3 foley irrigation, monitor to prevent blood clot formation
Note the Foley should be removed ASAP to prevent infection
Maintain protective isolation precautions and monitor for infection
Monitor IV fluids closely for fluid overload or oliguria
Isolation Precautions
Monitor for s/s of rejection
What are some s/s of Kidney transplant rejection
Oliguria (output less than 500 mL a day)
Edema (Check for weight - gain specifically)
Monitor for increased BP
*Some anti rejection meds may mask s/s of rejection so you really want to be diligent when assessing
Aspects of Client Education with Kidney Transplants
avoid prolonged periods of sitting
recognize s/s of infection and rejection
avoid contact sports
avoid exposure to people with infections
take medications as prescribed and know importance of maintaining immunosuppressive therapy for life
What is kidney transplant surgeyr like
sometimes the diseased kidney is left there and ureter is disconnected and attached to a new donor kidney
Nephrotic Syndrome
glomerular disease characterized by proteinuria, hypoalbuminemia, diffuse edema, high serum cholesterol, hyperlipidemia
basically any condition that seriously damages the glomerular membrane and increases the permeability to plasma proteins
Nephrotic Syndrome
glomerular disease characterized by proteinuria, hypoalbuminemia, diffuse edema, high serum cholesterol, hyperlipidemia
basically any condition that seriously damages the glomerular membrane and increases the permeability to plasma proteins
Etiology of Nephrotic Syndrome
any renal condition that damages glomerular capillary membrane
salt and water retention contribute to edema
thromboemboli are common
prognosis is poor (<50% experience complete remission adn at least 30% develop ESRF)
Assessment for Nephrotic Syndrome
severe generalized edema - results in edema which is usually dependent edema (hands, feet, and sacrum)
symptoms of renal failure
loss of appetite and fatigue
may also see ascites
Potential Causes for Nephrotic Syndrome
Glomerular Nephritis
Diabetes
Lupus
Multiple Myeloma
Renal Vein Thrombosis
Therapeutic Management for Nephrotic Syndrome
Non specific but therapeutic management for RF, edema, etc
Med management and diet therapy
What is unique about nephrotic syndrome compared to other renal issues
because of the increase plasma protein permeability with this specific sydrome you have to talk to them about INCREASING PROTEINS IN THE DIET
Nursing Dx for Nephrotic Syndrome
Fluid overload
Fatigue
Insufficent Ability to Perform Usual Roles
Planning and Interventions for Nephrotic Syndrome
control edema
high protein diet
administer drug therapy as prescribed
bedrest
monitor laboratory and diagnostic tests
observe for s/s of pulmonary edema
I/O and weight
fluid restriction
immune system depression increase risk of infection
Client Education Topics for Nephrotic Syndrome
efforts to maintain general health
avoid infection
nutritious diet
medications
knowledge of renal function
Potential Complications due to Nephrotic Syndrome
Infection - deficient immune response
Thromboembolism - in renal vein
Could cause acute renal failure (d/t hypovolemia associated with nephrotic syndrome)
