Renal/Urinary Flashcards
What does the kidney do?
- Filters waste
- Concentrates Urine
- Secretes Renin
- Secretes erythropoietin
- Maintains acid base balance
- Excretes excess K+
- Synthesizes component of Vitamin D
How do we measure Renal function?
- Serum Creatinine
- Creatinine clearance
- BUN (Blood urea nitrogen)
What is serum creatinine a measure of?
Byproduct of protein and muscle breakdown
What does creatinine clearnance measure?
- Measures GFR
(24 hour urine collection)
What does BUN measure? What can affect BUN?
Protein breakdown in the liver > Urea nitrogen
- Affected by dehydration, steroid use, etc
How to collect a urinalysis?
Clean catch vs catheterization
- Early morning sample if possible (Urine is most concentrated)
Process of 24 hour urinalysis
Discard 1st void, “ start time”
-Void in hat > Pour into specified container
- Missed urine compromises sample
- Store sample of ice or in refrigerator
Renal/Urinary Diagnostic procedures and what they are used to see?
- CT scan (Contrast CT)
- X-ray or KUB (Kidney, ureter, bladder)
- MRI
- Ultrasound
- VCUG (cystourethography voiding cystourethrogram)
- Cystoscopy
- IVP (intravenous pyelogram)
- Kidney Biopsy
- Renal Scan (nuclear medicine study: Tech99m-DTPA, GFR study)
What does X-ray or KUB (Kidney, ureter, bladder) used for?
Visualization of kidney size and location, detect stones.
What is a Kidney MRI used for?
used for cancer staging, soft tissue visualization
What is a kidney ultrasound used for?
Used for hydronephrosis
VCUG (cystourethography voiding cystourethrogram)
- Detects urethral or bladder injury
- Involves instillation of contrast dye through urinary catheter
- Provides image of bladder and ureter
Cystoscopy
- Scope procedure to examine abnormalities of bladder, ureter, urethra
- NPO after midnight, possible bowel prep
- Normal to see mild hematuria
- Encourage fluid intake post procedure
IVP (intravenous pyelogram)
Uses IV dye (injected into blood) to identify obstructions or disorders of ureters and renal pelvis
Kidney Biopsy
- Removal of a sample of renal tissue
- Excission or needle aspiration
Renal Scan (nuclear medicine study: Tech99m-DTPA, GFR study)
Assess renal blood flow
- Estimates GFR after IV injection of radioactive material
Suprapubic catheter
- Oldest simplest form of urinary diversion
- Catheter placed in bladder via a small incision in abdominal wall
- Temporary or permanent
Issues with suprapubic catheter
- Prone to poor drainage d/t mechanical obstruction of catheter tip on bladder wall
- Bladder spasms may occur
Antispasmodics (oxybutynin)
Belladonna, opium suppositories
Ileal Conduit
Section of ileum > conduit for urinary drainage
- Ureters are anastamosed into one end of the conduit
- Other end brought through abdominal wall to form a stoma
- No voluntary control > Requires appliance (Ostomy bag)
Continent Urinary Diversion
Intrabdominal urinary reservoir
- Catheterized OR outlet controlled by anal sphincter
- If catheterized > Must self-catch every 4-6 hours
- Does not need ostomy bag
Cutaneous Ureterostomy
- Urinary ostomy
- Urinary analog to colostomy
- No control of urine flow > Requires appliance
Nephrostomy Tubes
Temporary
- Preserve renal function when ureter is completely blocked (kidney stones)
- Catheter inserted directly into renal pelvis
- DO NOT CLAMP, COMPRESS, OR KINK
- High risk for infection
Bladder Reconstruction (Neobladder)
- New bladder made in correct anatomical position
- Made from segments of colon
- Urine discharged through urethra (natural micturition)
UTI
Infection of the urinary tract
Cystitis
Lower UTI
- Bladder infection
- Usually bladder specific syptoms
Pyelonephritis
Upper UTI
- Kidney infection
- Usually more systemic symptoms
- Usually begins as cystitis
- Repeat infections may cause scaring
- Most commonlt caused by E.coli
Chronic, Asymptomatic UTI
- Bacteriuria without symptoms
- May not need treatment
Female UTI Risk Factors
UTIs common
- Predisposed to UTI
- Short urethra
- Proximity of urethra to rectum
- Sexual intercourse (Pee after sex)
- Tight or restrictive clothing
Male UTI Risk Factors
UTIs rare
- More common in older (>50y) men
- Mostly caused by urinary retention r/t BPH
In young men with UTI symptoms > Test for STD too
Very common cause of UTI
Urinary catheterization
CAUTI
Catheter-associated UTI
- Most common HAI
- Commonly caused by E.coli or psuedomonas
CAUTIs are associated with increased ….
- Length of stay
- Health care cost
- Morbidity and Mortality
What is an important way to stop CAUTIs
Prevention is key
- Catheters only when needed
- HOUDINI or other nurse driven removal protocol
UTI manifestations
- Dysuria
- Urinary frequency and urgency
- Cloudy, foul smelling urine
- Low back pain and abdominal tenderness
- Fever? (unreliable indicator of UTI)
UTI manifestations - Geriatric Patients
- Confusion
- Incontinence
- Anorexia
- Nocturia
UTI Diagnosis
Urinalysis with culture and sensitivity
- Usually clean catch
- positive leukocyte esterase
- Bacteriuria
- WBC in urine
- Start antibiotic > Change as appropriate when C&S results come back
- Serum WBC elevated
- Consider ruling out STD
UTI Treatment
- Fluid intake (3L/Day)
- Frequent urination (q 3-4 hrs)
- Heat to lower abdomen for pain
- Antibiotics
- Cranberry Juice
What med can you give for UTI and what happens
Phenazopyridine
- Decreases dysuria
- Turns urine orange
Acute Pyelonephritis
Active Bacterial infection
Can cause:
- Interstital Inflammation
- Acute tubular necrosis
- AKI
- Abscess
Chronic Pyelonephritis
Result of repeated infections > Progressive Inflammation > Scarring
Can cause:
- Thickened Calyces
- Post-inflammatory fibrosis
- Permanent renal tissue scaring
Pyelonephritis Complications
- Hypertension (Due to destruction of glomeruli) (Renal function decreases > Fluid overload)
- CKD (Chronic kidney disease) (Due to renal fibrosis, scarring, vascular and tubular changes)
- Sepsis (Hypotension, Tachycardia, Fever)
Pyelonephritis S&S
- Chills
- Renal Colic
- CVA tenderness
- Flank and back pain
- Fever
- Hematuria
Pyelonephritis Treatment
Similar to Cystitis
- Increase fluid intake
- Antibiotics
- Surgery (Pyleolithotomy - Removal of stones, Nephrectomy - Removal of kidney, Ureteroplasty - Repair or ureter)
Urosepsis
Sepsis due to UTI (LIFE THREATENING)
- Shock and Organ failure
Urosepsis Treatment
Antibiotics
Fluid intake
Monitor for s&s of worsening sepsis (Hypotension, Tachycardia, oliguria)
When does Nephrotic syndrome typically occur, and what is its presentation
Glomerular changes at ages 2-5
Presentation
- grOss prOteinuria
- hypOablbuemia
- swOllen (facial first > abdomen and extremities)
Nephrotic syndrome treatment
- sterOids
- lOw sodium, pOtassium, fat diet
- prOtein
When does Nephritic syndrome typically occur, and what is its presentation
Glomerular inflammation at age 2-10
Presentation
- post Infection (strep) Inflammation
- gross hematuria (pepsI-colored urine)
- mIld proteinuria
- mIld edema (facial)
-h”I” pertension
- h”I” BUN/creatine
Nephritis treatment
- dIuretics
-h”I” pertension meds - moniter for h”I”perkalemia
Obstructive uropathy (common causes)
Any anatomic/functional condition that blocks urine flow
- Urolithiasis (Kidney stones)
- BPH
BPH Diagnosis and Treatment
BPH- Common reason for obstruction in men >60 y
Diagnosis: PSA (prostate-specific antigen)
Treatment: Gold standard is TURP (transurethral resection of prostate)
Renal Calculi types
- Calcium (Most common)
- Struvite (associated with chronic uti)
- Uric acid (Gout, high protein diet)
- Cystiene (least common due to metabolic disorder)
- Strong familial component (likely to recure)
Renal Calculi S/S
Severe pain
Urinary frequency
Dysuria
Fever
Diaphoresis
N/V
Hematuria
May progress to hydronephrosis
Renal calculi diagnostic testing
UA
KUB
IVP
CT
Renal ultrasound
Renal calculi treatment
Opioids
NSAIDs (ketorolac)
Antispasmodic (oxybutynin)
Therapeutic interventions
- Lithotripsy
Surgery
- Stenting
- Ureteroscopy, ureterolithotomy
Renal calculi education
Calcium Stones
- Reduce calcium intake
- Limit foods high in protein
Uric Acid
- Limit foods high in protein, organ meat
Struvite
- Avoid high phosphate diets
Polycystic Kidney Disease
- Congenital disorder (10-15% of CKD)
A cluster of fluid-filled cysts develops on the
nephrons (may also develop systemically - Heart, liver, intestine, brain)
Polycystic Kidney Disease Treatment
Needle aspiration of cysts
Kidney transplant
Acute Kidney Injury + Phases
Sudden decrease in renal function
Occurs when blood flow to the kidney is compromised
- Onset (initial injury)
- Oliguria (low urine output)
- Diuresis (Not properly concentrating urine)
- Recovery
Prerenal acute kidney injury
Usually due to decreased renal perfusion
- Shock
- Sepsis
- Hypovolemia
- Nephrotoxic medications (Can also be classified as intrarenal)
Intrarenal acute kidney injury
- Trauma
- Hypoxic injury (thrombosis)
- Chemical injury (Contrast dye, heavy metals, blood transfusion reactions)
- Immunological injury (Infection, glomerulonephritis)
Acute tubular necrosis
The most common cause of Intrarenal acute kidney injury
- primary result of ischemia
- Necrosis > Cells slough off > form embolus in renal tubuls
Post renal acute kidney injury
Due to obstruction below the kidney
- Stones
- Tumor
- Bladder
- BPH
- Spinal cord disease/injury
Acute kidney injury s/s
- Fluid overload
- Dysthymia (hyperkalemia)
- Crackles in lungs
- Minimal urine output
- Lethargy, twitching, seizures
- Dry mucous membrane
Acute kidney injury treatment
IV fluids
- Monitor for fluid overload
Diuretics
Correct electrolyte imbalances
Temporary dialysis as necessary
Chronic Kidney disease
- Progressive, Irreverible
Stages 1-5
CKD s/s
Neuro
- Lethargy, slurred speech, tremors
Cardiovasular
- Fluid overload, edema, HTN, HF, dysrrhthmias
Respiratory
- SOB
- Crackles
- Kussmaul respirations
- Uremic Halitosis
Hematological
- Anemia
MSK
- Osteodystrophy
Integumentary
- Uremic Frost
Dialysis
Life saving in renal disease
Function
- Rids body of excess fluid and electrolytes
- Achieve acid base balance
- Eliminates waste products
- Restores internal homeostasis via osmosis, diffusion, ultrafiltration
Peritoneal dialysis
Instillation of hypertonic dialysate solution into the peritoneal cavity
- Dwells for length of time then is drained (usually overnight)
Complications
- Peritonitis
- Infection at access site
Hemodialysis
Shunts blood away from body through a dialyzer then back into circulation
- Occurs usually 3x a week
- Monitor client continuously during dialysis
Temporary hemodialysis
Usually Central venous catheter (CVC)
Permanent Hemodialysis
AV fistula
- Anastomosis between atery and vein
- Provides rapid blood flow and pressure for HD
- Expect thrill and bruit
Graft
- Synthetic vessel
Continuous renal replacement therapy (CRRT)
- 24hr dialysis for hemodynamically unstable clients
- Removes uremic toxins
- Acid base balance adjusts slowly and continuously
- Closer to normal physiology
Kidney transplant
Option for ESRD
- Much high demand than supply
Transplants are very successful
- Usually last 12-15 years
- Dead kidney is not removed
Kidney transplant aftercare
Monitor for infection
- Clients on Life long immunosuppressants
Monitor for organ rejection
* Hyperacute (48hrs)
- Fever, HTN, Pain
- Acute (2 years)
- Antibody-mediated response
- Inflammation > Lysis of the donor kidney
*Chronic (gradual)
- Blood vessel injury > Fibrotic tissue > Kidney failure
Intake
Anything we can measure that is put into the body (Liquids)
Measured in ML
Output
The fluid that leaves the body
- Urine, Vomitm liquid stool, drainage
Measured in ML
What is urine output meausred in
ml/kg/hr
Net fluid or fluid balance
Intake - Output = Net fluid or fluid balance
What are key differences in pediatrics than in adults
- Immature kidney function
- Smaller bladder capacity
- Higher risk for infections
Types of urine collection in pediatrics
- Clean catch
- Urine bag (wee bag)
- Catheterization
- Suprapubic aspiration
Nursing priorities to monitor in pediatric clients
1.) Fluid and electrolyte balance (monitor I&O, recognize dehydration/fluid overload)
2.) Infection prevention (Promote good hygiene, timely administration of antibiotics
3.) Family education and support (Teach about condition, medication adherence, and lifestyle modifications)
