Urinary disorders Flashcards
Urinalysis
evaluate renal system and renal disease
Urine culture and sensitivity
determines the presence of microorganisms (culture) and appropriate antibiotic treatment (sensitivity)
Specific gravity
ability of the kidneys to concentrate urine (decrease may indicate renal disease)
1.005-1.030
Creatinine
increase occurs when at least 50% of renal function is lost; Reflects glomerular filtration rate
1
Glomerular filtration rate (GFR)
estimates how much blood passes through the tiny filters in the kidneys (glomeruli) each minute.
125 ml/min
BUN blood urea nitrogen
levels indicate the extent of renal clearance of urea nitrogenous waste products
Increase may occur from dehydration, high protein diet, infection, stress, corticosteroid use, GI bleed, factors that cause muscle breakdown
7-20
Creatinine clearance
determines how well kidneys excrete creatinine; 24 hour urine collection and serum creatinine collection (estimates GFR)
Cystitis Dx and CM
Dx: Urinalysis- leukocyte esterase (infection) and nitrate (bacteria)
Urine culture: expensive, 48 hours, indicated when uti is complicated.
Serum WBC- may be elevated with a left shift - increased bands
CM:fever, burning with pain, foul odor to urine, lower stomach pain, chills, increased wbc, cloudy urine, back pain
Cystitis Tx
Nonsurgical Management
Medications – antibiotics, antiseptics, (promote comfort) analgesics, antispasmodics (decrease bladder spasm and promote bladder emptying)
Nutrition – H2O, cranberry juice (alkalotic urine promotes bacteria growth)
Warm sitz baths
Surgical Management
Removal of obstruction or repair of vesicoureteral reflux
Cystoscopy – remove calculi or obstructions
Urethral Strictures
Narrowed areas of the urethra
Causes - complications of a STD, trauma during childbirth, catheterization, or urologic procedures
May lead to overflow incontinence, also urinary retention in the bladder which leads to recurrent UTIs
Urethroplasty – surgical removal of the affected area
Urinary incontinence
Most common in older adults and women.
Lab assessment to rule out UTI
Stress incontinence
Most common type
loss of small amounts of urine while coughing, sneezing, lifting, exercising
common after childbirth
avoid caffeine, alc, nicotine, sugar
Urge incontinence
“Overactive bladder”
inability to relax the detrusor muscle leading to a strong urge to void and often leakage of large amounts of urine
Causes – stroke, other neurologic problems, urinary tract problems, irritation from concentrated urine or artificial sweeteners, caffeine, alcohol, citric intake, diuretics, and nicotine
scheduled bathroom times
Mixed incontinence
often stress and urge incontinence
More common in older women (during or after menopause)
Overflow incontinence
“reflex incontinence”
detrusor muscle fails to contract and the bladder becomes overdistended
Bladder reaches maximum capacity and some urine must leak out to prevent bladder rupture
Causes – urethra may be obstructed (enlarged prostate, stone, stricture, tumor, genital prolapse) leading to incomplete bladder emptying or urinary retention
Treatment – surgery to relieve obstruction or repair of genital prolapse
Behavioral interventions - most effective is intermittent catheterization; bladder compression
Functional incontinence
Due to loss of cognitive function (or physical or social impairment such as stroke or cognitive disability)
Treatment – habit training
Women – intravaginal pessary – device supports the uterus and vagina and helps maintain the correct position of the bladder
Urolithiasis
Presence of calculi (stones) in the urinary tract
Nephrolithiasis – formation of stones in the kidney
Ureterolithiasis – formation of stones in the ureter
Hydroureter
(ureter dilation) may occur if the stone occludes the ureter and blocks the flow of urine
Hydronephrosis
enlargement of the kidney with urine due to a blockage in the lower tract
–>Oliguria (100-400 ml/d) or anuria (
Urolithiasis
CM, Complications, Tx
Manifestations: sharp/excruciating pain, may cause pt to be nauseas, may be hematuria, difficulty voiding, frequency
Complications: Hydroureter, Hydronephrosis –> Oliguria (100-400 ml/d) or anuria (3L/day to prevent obstruction and promote urine flow
Urothelial Cancer
Malignant tumors of the lining of transitional cells in the kidney, renal pelvis, ureter, bladder (most common), and urethra
Urothelial cancer risk factors, CM and Tx
Risk factors – tobacco use and exposure to harmful environmental agents
Tumors confined to the bladder -treated with a simple excision; Invading bladder muscle layer treated with excision and intravesical (inside the bladder) chemotherapy; Invading deep muscle layer treated with radical cystectomy with urinary diversion, chemotherapy, and radiation
Manifestations – subtle- painless intermittent gross or microscopic hematuria
Surgical Management after cystectomy
Anuric after bladder trauma
urine prob going into abdominal cavity so it’s an emergency
Polycystic kidney disease (PKD)
inherited disorder in which fluid-filled cysts develop in the nephrons
As the cysts fill with fluid and enlarge, the nephron and kidney function become less effective
Cysts are at risk for infection, rupture and bleeding
Leads to HTN
Polycystic kidney disease (PKD) CM and Tx
U/A - proteinuria (glomerular damage) and hematuria
Manifestations – dull, aching pain (occurs early) due to increased kidney size (distended abdomen; kidneys palpable); sharp pain, bright red or cola-colored urine (from ruptured cyst), nocturia (decreased urine concentrating ability)
Later S/S – increasing HTN, edema, and uremic problems (anorexia,
N/V, fatigue, pruritus)
Pain – drug therapy and complementary approaches
Caution w/NSAIDs b/c reduces renal blood flow
Severe pain – cyst aspiration and drainage of cysts
Antibiotics if cysts infected
HTN/Renal Failure – 2L fluid/day to prevent dehydration (reduces renal function); restrict Na intake; antihypertensives and diuretics; if renal failure progresses – limit protein intake
Pyelonephritis
bacterial infection in the kidney and renal pelvis (most common organism – E.Coli)
U/A - + leukocyte esterase and nitrites, WBCs, and bacteria
Causes of pyelonepthritis
Acute – active bacterial infection; usually due to obstruction, pregnancy, reflux
Chronic (may be asymptomatic) – repeated or continued infection; causes –urinary tract defect, obstruction (tumor, stone, and enlarged prostate in >65yo), or infected urine reflux (most common cause) from bladder to ureters - vesicoureteral junction
Other causes of both – urinary catheter, DM (reduced bladder tone), NSAIDs (papillary necrosis and reflux)
Glomerulonephritis (GN) and Tx
glomerular injury resulting in proteinuria, hematuria, decreased GFR, edema, and HTN and headache
maintain bed rest to protect kidney, restrict fluids, reduce protein and sodium but increase calories, monitor daily weight
Penicillin, steroids, anti hypertensives
Acute Glomerulonephritis (GN)
infection usually precedes; usually recover quickly and completely
U/A – proteinuria, hematuria (usually microscopic – smoky, reddish brown, rusty, or cola colored urine); serum albumin decreased b/c of proteinuria and fluid retention causing dilution
Elevated BUN, creatinine, and decreased GFR
Diagnosed by renal biopsy
Chronic glomerulonepphritis
develops over 20-30 years; unable to determine cause b/c kidneys are atrophied and cannot be biopsied
Always leads to ESKD - 3rd leading cause of ESKD
Exact cause unknown, however, changes in kidney tissue result from HTN, DM, infections and inflammation, or poor blood flow to the kidneys (nephrotoxic drugs)
Manifestations – mild proteinuria, hematuria, HTN, fatigue, decreased UOP, and fluid overload
Nursing Considerations
Management – slow the progression and prevent complications
Dietary (restrict fluid and Na, but fluid intake sufficient to prevent reduced renal blood flow), medications for uremic symptoms (protein restriction)
Assess for fluid overload- crackles, edema, increased BP, weight gain
Fluid restriction = 24 urinary output + 500 ml
Nephrotic syndrome
group of symptoms, not a disease
increased glomerular permeability leading to massive loss of protein in urine, edema and decreased plasma albumin levels
Interstitial nephritis
Kidney disorder in which the spaces between the kidney tubules become swollen (inflamed) affecting the kidneys’ function
If drug induced – often a rash and elevated eosinophil count
Progression to ESKD unless cause is identified and removed (ex. – avoid medication)
Nephrosclerosis
thickening in the nephron blood vessels, resulting in narrowing in the vessel lumen
Decreased renal blood flow, chronically hypoxic kidney tissue, ischemia and fibrosis develop over time
Occurs with all types of HTN, DM, and atherosclerosis
Nursing Considerations – control HTN and reduce albuminuria to preserve renal function (ACE inhibitors)
Renovascular disease
Renal artery stenosis (RAS) from atherosclerosis or blood vessel hyperplasia is the main cause of renovascular disease.
Renovascular disease causes ischemia and atrophy of kidney tissue.
CM: may have sudden onset of HTN
Tx: control HTN
Diabetic nephropathy
The leading cause of ESKD
1st manifestation – persistent albuminuria – often cause for a renal biopsy
The leading cause of ESKD
Renal cell carcinoma
Cancer of the lining of the renal tubules
Most common renal cancer in adults (men aged 50-70 yo)
Complications – metastasis and urinary tract obstruction
CM: Flank pain, hematuria
Tx: kidney needs to be removed bc chemo and radiation isnt effective
Renal trauma
Pedicle injuries
lacerations in the renal artery or vein; Rapid Hemorrhage and death may occur
Kidneys are very vascular
Acute renal failure
Rapid decrease in kidney function
Can be caused by trauma, allergic reactions, kidney stones or shock (drink 2-3L/day)
Pre, intra or post renal failures
Monitor Decreased urine specific gravity – loss of urine concentrating ability (earliest sign of renal tubular damage)
Elevated BUN/Creatinine, electrolyte imbalances, usually NOT anemia
Tx: phosphate biders to lower phosphorus while replacing calcium
Prerenal failure
reduced blood flow to the kidneys (severe hypotension from hypovolemic shock, dehydration, or heart failure)
CM:hypotension, tachycardia; decreased UOP, cardiac output, and CVP; and lethargy
Intrarental failure
damage to the glomeruli, interstitial tissue, or tubules (infections, nephrotoxic drugs, glomerulonephritis, vasculitis, obstructed renal blood flow)
CM: oliguria, anuria, edema, HTN, tachycardia, SOB, distended neck veins, elevated CVP, wt gain, crackles, anorexia, N/V, lethargy, LOC change, hypocalcemia and hyperkalemia
Postrenal failure
obstruction of urine flow from kidney (cancer, stones, strictures, BPH)
oliguria, intermittent anuria, symptoms of uremia, and lethargy
azotemia
build-up of nitrogenous wastes
Chronic kidney disease
Progressive and irreversible
5 stages of CKD – glomerular filtration rate decreases with each stage – 5th stage is End Stage Kidney Disease (ESKD)
2 most common causes are DM and HTN
CKD affects on the body
Metabolic changes – urea and creatinine excretion is disrupted
Early = hyponatremia
Later = hypernatremia; hyperkalemia (fatal dysrhythmias); metabolic acidosis; hypocalcemia/hyperphosphatemia
Cardiac changes – HTN; hyperlipidemia; HF; pericarditis
Hematologic changes - anemia (later stages)
GI changes – uremia leads to halitosis, stomatitis, anorexia, N/V, hiccups, and peptic ulcer disease
Hemodialysis
Removes excess fluids and wastes products and restores chemical and electrolyte imbalances
Patient’s blood passes through an artificial semipermeable membrane to perform the filtering and excretion functions of the kidney
When to start – not based on GFR, based on patient’s symptoms
Requires good vascular access (large amount of blood flow – 250-300ml/min during the 3-4 hour treatment)
Weight pt before and after, assess for thrill and bruit, withhold bp meds
Post hemodialysis complications
hypotension (hold vasoactive drugs before HD), headache, N/V, malaise, dizziness, and muscle cramps
Must be done gradually or risk for DDS (dialysis disequilibrium syndrome)- Clinical signs of cerebral edema, such as focal neurological deficits, papilledema[4] and decreased level of consciousness, if temporally associated with recent hemodialysis, suggest the diagnosis.
Hemodialysis vascular access
AV fistula – formed by connecting (anastomosis) an artery to a vein
AV graft – the graft is make of synthetic material
Want to hear a bruit and feel thrill over fistula or graft site- indicative of patent fistula or graft
No IV sticks or lab draws or bp in arm with fistula or graft
Continuous Renal Replacement Therapy (CRRT)
Standard treatment for ARF (& CRF) in ICU setting
Kinder gentler better tolerated type of dialysis
Similar to HD, but temporary – avoids rapid shifts in fluid and electrolytes
Indications - fluid volume overload, diuretic resistance, unstable blood pressure and cardiac output
Peritoneal Dialysis
A rubber catheter is surgically placed in the abdominal cavity for infusion of dialysate. Perineum is used as a filter for the kidney.
1-2L of dialysate infused by gravity or by PD machine, the fluid stays in the cavity for a specified time, the fluid then drains by gravity or PD machine into a drain bag which equals 1 exchange- fluid should be clear and pale yellow
The peritoneal outflow contains dialysate and excess water, electrolytes, and nitrogen-based waste products
Complications – peritonitis (connection site contamination) –cloudy outflow, fever, abdominal pain, malaise, N/V
Renal transplant
Not a cure – requires lifetime medications; risk for rejection, infection, and cancer due to immunosuppression
Typical age range – 2-70 yrs.
Exclusion criteria – advanced cardiac disease, cancer in the last 2-5 years, all metastatic cancer, chronic infection, alcohol or other substance abuse
Renal transplant complications
ATN – acute tubular necrosis – results from hypoxic damage when there is a delay in organ recovery to transplantation
Thrombosis – occurs in major renal blood vessel usually 2-3 days after transplant – diagnosed by renal scan and requires immediate surgical repair
Infection – major cause of death and must be prevented with drug therapy, aseptic technique, and hand washing
Acute rejection: 1week-2 years after transplate
Chronic rejection: months-years
Symptoms of rejection: flu symptoms, fluid retention, oliguria, fever
