Renal & Urinary Disorders Flashcards
Acute kidney injury
- Rapid and acute dz process affecting kidney
- Reversible in most cases
- Delay in treatment = CKD
- Increased incidence: hospitalized pts undergoing surgery or w acute illness, CV dz & DM, aged population
Chronic kidney disease
- Develops after months to years (silent dz)
- Irreversible
- Eventual management is long-term dialysis or renal transplant
- Careful monitoring and patient adherence improves outcomes
Prerenal causes of AKI
Conditions not related to kidney system (poor perfusion)
- Hypovolemia
- Decreased cardiac output
- Decreased peripheral vascular resistance
- Vascular obstruction
Infrarenal causes of AKI
Direct damage to renal parenchyma & result in impaired nephron function
- Prolonged ischemia
- *Nephrotoxins: Aminoglycoside, Antibiotics (Tobramycin, Gentamicin, Neomycin) = #1 cause
- Contrast dye used in imaging studies
- Hgb released from RBC hemolysis (eg. DIC)
- Myoglobin released from necrotic muscle cells
Postrenal causes of AKI
Mechanical obstruction of lower urinary tract (ureters, bladder, urethra)
- BPH
- Prostate CA
- Calculi
- Trauma
- Tumors
AKI complications
Hyperkalemia –> life-threatening cardiac arrythmias
AKI fluid volume
Initially fluid volume deficit, then fluid volume overload
AKI nursing assess
- VS: initially hypotension & tachy (FVD), then hypertension (FVO)
- Urine output: initially decreased, then increased
- FVO signs: bounding pulse, edema, HTN, JVD
- FVO causing decreased breath sounds, low O2 (rales)
AKI nursing assess (labs)
- Elevated K, Phos, BUN/Cr
- Decreased Na, Hgb, Hct, Ca
- ABG: metabolic acidosis, low bicarb
AKI nursing intervention
- Manage fluid balance & daily weights: I&Os, provide fluids to ensure vol, restrict fluids in FVO
- Administer meds as ordered: diuretics, potassium lowering therapy
- Mobility & skin care
- Monitor and document food intake
AKI pt teaching
- Knowledge of cause and treatment of AKI, rationale for fluid and dietary restricts
- Help manage anxiety
- Adherence w treatment, med education
- Avoid nephrotoxic substances
CKD risk factors
- Uncontrolled diabetes
- Uncontrolled HTN
CKD clinical manifestations
Na/H2O balance:
- HTN, heart failure, pulm edema
Hyperkalemia:
- Lethal arrythmias
Metabolic waste build-up (uremia):
- GI (N/V, anorexia)
- Neuro (headache, lethargy, confusion)
- Untreated (sz & coma)
Hypocalcemia/Hyperphosphatemia:
- Bone breakdown
- Bone pain and fractures
Decreased acid clearance & bicarb prod:
- Metabolic acidosis
Decreased erythropoietin prod:
- Anemia
Endocrine and reproductive dysfunction:
- Infertility, amennorhea
- Hyperparathyroidism, thyroid abnormalities
CKD renal transplant contraindications
- Untreated or metastatic cancer
- Refractory CAD or heart dz
- Psychosocial issues: hinder compliance w life-long treatment regimen (eg. persistent drug use or severe psychiatric disorder)
Renal transplant
- Lifelong management of dz & immunosuppression (NOT a cure)
Renal transplant types of donors
Matched via national registry (UNOS)
- Deceased or cadaver donor (most common)
- Living-related donor or living unrelated donor
Renal transplant risks of immunosuppression
- Infections of blood, lungs, CNS (fungal = high mortality)
- Malignancies
- Congenital anomalies in infants (of mothers undergone immunosuppressive therapy)
- Corticosteroids: bone problems, GI disorders, cataracts
CKD nursing assess
- VS: HTN, low O2 sat in FVO or atelectasis post surgery
- FVO: rales on auscultation, JVD, peripheral edema
Labs:
- High K
- Na
- Low Ca, High Phos
- Low Hgb, Hct
- Metabolic acidosis, decreased bicarb prod, decreased H+ clearance
- Renal function tests
CKD nursing interventions
- Cardiac monitoring: hyperkalemia
- I&Os, daily weights
- Restrict fluids/sodium
- Skincare/proper positioning
- Renal diet; low protein
- Administer prescribed meds: antihypertensives, Ca supplements, erythropoietin, phosphate binders, folic acid and ferrous sulfate, immunosuppression, pain meds
CKD pt teaching
- Dialysis & appointment sched
- Dietary restrictions
- Clinical manifestations of CKD & complications
- Avoid nephrotoxic substances: NSAIDs, contrast media, certain abx, alc
- Daily weights
- Post-transplant: info regarding immunosuppression meds
- Avoid exposure to infections
Dialysis
Blood separated from dialysis solution (dialysate) by semipermeable membrane
- Diffusion removes waste over semipermeable membrane
- Filtration removes excess water via hydrostatic pressure
HD access (AV fistula)
- Long-term
- Surgical anastomosis btwn radial artery and cephalic vein
- Maturation required: low press vein becomes accustomed to higher press generated by artery
- Can take weeks to months; alternative access for HD in meantime
Functional AV fistula assessment
- Palpable pulsation (thrill)
- Bruit upon auscultation
- No BP, IV, blood draws
HD basic process
- Blood pumped from body to dialyzer
- Blood moves across semipermeable memb
- Concentration gradient causes diffusion, excess fluid removed via hydrostatic press
- “Clean” blood moved back to vascular access
Benefits of PD
- Increased pt control and flexibility
- Home therapy
- Shorter learning period for pt
- Performed by pt or family member
- Fewer dietary restricts
- Greater mobility for pt
PD basic process
At peritoneal cavity
- Dialysate instilled into peritoneal cavity, remains w waste & electrolytes diffusing into dialysate
- Gravity drains fluid out of peritoneal cavity into sterile bag
UTI risk factors
- Female (short urethra, proximity to vagina and rectum)
- Sexual activity
- Diabetes
- Poor hygiene
- Estrogen deficiency
- *Recent catheterizations
- Foreign objects (eg kidney or bladder stones)
- Conditions causing incomplete bladder emptying: pelvic organ prolapse, nerve or muscle damage post-surgery, neurological conditions
UTI localized symptoms
- Bladder irritability
- Dysuria = painful urination
- Urinary freq, urgency
- Hematuria (gross/microscopic)
- Small vol voiding
- Suprapubic pain
UTI systemic symptoms
Pyelonephritis: infection has spread to kidney OR urosepsis: infection has spread to blood
- Fever
- N/V
- Flank pain
Uncomplicated UTI medical management (nonpregnant females)
3 day course of abx, usually Bactrim or Cipro
Complicated UTI medical management (fever, male, diabetes)
7 day course abx based on culture and sensitivities
UTI nursing assess
- VS: elevated temp, HR, decreased BP
- Urinary sympts: dysuria, urinary freq, urgency, gross hematuria
- Abd exam: suprapubic tenderness, CVA tenderness
- Urinalysis: hematuria, leukocytes, nitrites, cloudy urine w foul odor
- Urine culture: > 100,000 bacteria, active infection, sensitivities dictate abx choice
UTI nursing interventions
- Administer abx as ordered
- Administer bladder analgesics: Phenazopyridine (Pyridium), short-term use only 3 days in order not to mask UTI sympts
UTI pt teaching
- Reportable sympts of UTI: fever, flank pain, N/V, indicate pyelonephritis/renal abscesses
- Increase fluid intake
- S&S of UTI
- UTI prevention: hygiene and hydration
Pyelonephritis risk factors
Vesicouretal reflux (retrograde flow of urine from bladder to ureters):
- Primary: congenital defect in valve
- Secondary: failure of bladder to empty d/t obstruction
- Obstruction: BPH, strictures & stones
- Long-term indwelling catheter
- Pregnancy
- Sexual activity in women
Pyelonephritis clinical manifestations
- S&S of infection: fever, chills, tachy, N/V
- Back or flank pain
- CVA tenderness
- Enlarged kidneys
- Manifestations of UTI: urinary freq, dysuria, hematuria
- Elderly: *delirium
Pyelonephritis medical management
- Broad-spectrum abx w an aminoglycoside
- Bactrim or Ciproflaxin
- *Fluid replacement
- NSAIDS to reduce pain
- Meds to reduce fever
- *Pyridium relieves lower urinary tract pain, burning and urgency
Pyelonephritis nursing assess
- VS: hypotension, tachy, tachypnea, fever
- Pain: location (flank, groin pain)
- Assess urine output: urine characteristics, cloudy, odor
- Neuro: AMS in elderly common w UTI/Pyelonephritis
Pyelonephritis nursing interventions
- Administer prescribed abx, pain meds, supportive care
- Provide adequate hydration (prevent urinary stasis, ensure adequate circulating vol)
Pyelonephritis pt teaching
- *Explain dz condition
- *How to avoid UTI: regularly empty bladder, hydration, hygiene, unsweetened cranberry juice
Urolithiasis
Microscopic crystals in urinary tract come together and create stone
Pyelonephritis
Inflamm of renal parenchyma and urinary collecting syst
UTI
Bacteria enter sterile bladder and cause inflamm
Urolithiasis risk factors
- Male > female
- Caucasians > blacks
- Developed countries
- Increased freq of occurence: southeastern states & summer months (d/t dehydration)
- Family hx
- Dietary habits (high sodium and/or protein intake)
- Prev hx of stone formation
Urolithiasis clinical manifestations
- *Severe colicky pain when stone lodges in ureter d/t distension & obstruction of urine flow
- N/V
- Upper ureter: flank pain, lower ureter: genital and lower abd pain
- Gross hematuria or microscopic hematuria
Urolithiasis diagnosis
- Non-contrast CT scan stone
- KUB x-ray
Urolithiasis complications
- Pyelonephritis
- Urosepsis
- Irreversible renal damage
- Ureteral stent or nephrostomy tube may be necessary
Urolithiasis nursing assess
- VS: increased HR/RR, increased temp/hypotension
- Pain or renal colic: location of pain indicates stone location
- N/V
- Urine pH
- Urine culture
- Labs: WBC increase, BUN/Cr increase
Urolithiasis nursing interventions
- Administer meds: opioids, antiemetics, alpha-blockers (Flomax)
- Maintain fluid status
- Strain urine: collect stones for urinalysis
- Foley catheter insertion if pt can’t void
Urolithiasis pt teaching
- Trial passage pts: when to call provider (fever, chills, pain, N/V), strain urine to obtain stone
- Kidney stone prevention: hydration, low sodium diet, increase citrate in diet (lemons), decrease oxalate (coffee)
Benign Prostatic Hypertrophy
Small gland surrounding urethra size of a walnut –> compress urethra and interfere w flow of urine from bladder
BPH complications
- AUR (acute urinary retention)
- UTI
- Bladder stones
- Bladder damage
- Kidney damage: increased press causing hydronephrosis
- Pyelonephritis
BPH alternatives
If meds & surgery are not an option:
- Intermittent catheterization or indwelling catheter to manage obstruction & incontinence
BPH nursing assess
- VS: fever can indicate UTI
- Urinary sympts
- Focused abd exam: bladder distension
- Bladder scan: estimate of post-void residual, determine ability to empty bladder
- Urinalysis
BPH nursing interventions
- 5 alpha reductase inhibitors: limit prod of DHT –> encourage prostatic hyperplasia
- Alpha adrenergic blockers: relax smooth muscle
- Catheterization: check for post-void residual
- Relieve bladder distension
BPH pt teaching
- Watchful waiting: recognition of worsening sympts
- Decrease liquid intake
- Med therapy education
- Info regarding surgical options
- Routine follow-up w provider
BPH med teaching
- 5-alpha reductase inhibitors: decreased libido, erectile dysfunction, rash, breast enlargement & tenderness
- Alpha-adrenergic blockers: HA, dizziness, drowsiness, nasal congestion, postural hypotension, reflex tachy
