Urinary Elimination Flashcards
these organs help maintain body fluid volume and composition, filter waste products for elimination, regulate blood pressure/acid-base balance, produce erythropoietin for RBC synthesis, and convert vitamin D to an active form.
kidneys
the blood supply to each kidney comes from the _________.
renal artery
__________ promotes the reabsorption of sodium in the DCT.
aldosterone
______ increases tubular permeability to water, allowing water to leave the tube and be reabsorbed into the capillaries. acts within the DCT and CD; released from posterior pituitary
ADH; vasopressin (arteriole constriction)
The kidneys produce..
renin, prostglandins, bradykinin, erythropoietin, activated vitamin D
released when there is a decrease in blood flow, blood volume, or blood pressure through the arterioles or when too little sodium is present in kidney blood.
renin
what releases angiotensinogin II?
renin
increases systemic blood pressure through powerful blood vessel constricting effects and triggers the release of aldosterone from the adrenal glands
angiotensinogin II
produced when protein or muscle breaks down. filtered by kidneys and excreted in urine. Good indicator of kidney function.
creatinine
the by-product of protein breakdown in the liver
urea
increasing BUN more than creatinine BUN:creatinine ratio
deficient blood volume or low cardiac output
elevated BUN:creatinine ratio
kidney dysfunction that is not related to dehydration or poor perfusion
a measure of the overall concentration of particles in the blood and is a good indicator of hydration status
blood osmolarity
the rate of glomerular filtration (GFR) in the kidneys is altered by what
blood flow the kidneys
Which lab value most accurately reflects possible renal dysfunction? a. Urine specific gravity of 1.020 b. BUN/creatinine ration of 10:1 c. BUN of 15 mg/dl d. Creatinine of 5.0 mg/dl
d. Creatinine of 5.0 mg/dl
The rate of glomerular filtration (GFR) in the kidneys is alter by what?
blood flow to the kidneys
Antidiuretic hormone (ADH) acts within the _______ to promote reabsorption of _______.
distal tubules; water (via sodium)
the presence of calculi (stones) in the urinary tract. Stones often do not cause symptoms until they pass into the urinary tract.
Urolithiasis
the formation of stones in the kidney
Nephrolithiasis
formation of stones in the ureter
Uterolithiasis
With which type of urinary diversion will male clients need to learn to sit to urinate?
Diversion into sigmoid colon
Symptoms of prerenal azotemia
hypotension tachycardia decreased CO decreased central venous pressure (taken by Swann Gan) decreased urine output lethargy
kidney injury caused by poor blood flow to the kidneys
prerenal azotemia
administering normal saline 500 to 1000ml infused over one hour
fluid challenge
indications for dialysis in the client with acute renal failure
presence of uremia, persistent high potassium levels, metabolic acidosis, continued fluid overload, uremic pericarditis, and encephalopathy
used for patients who have fluid volume overload, are resistant to diuretics, and have unstable blood pressures and cardiac output can regulate rate (less hemofluctuation)
continuous arteriovenous hemodialysis and filtration (CAVH)
risk associated with use of a pump in continuous arteriovenous hemodialysys and filtration (CAVH)
air embolism, bleeding caused by anticoagulants used to prevent membrane clotting
most accurate ways to monitor kidney function
urine output, BUN:creatinine ratio (both elevated =problem)
decreased serum creatinine level
decreased muscle mass
Normal BUN range
~10-20
increased BUN
hepatic or renal disease, dehydration or decreased kidney perfusion, high protein diet, infection, stress, GI bleeding
if liver and kidney dysfunction are present, urea nitrogen levels are ______ because liver failure limits urea production
decreased
the density of urine compared with water (1.00)
specific gravity
divert urine directly to the skin surface through a ureteral skin opening (stoma). Pt will wear a pouch.
ureterostomies
collect urine in a portion of the intestine which is then opened onto the skin surface as a stoma. Pt will wear a pouch.
conduit
divert urine to the large intestine. no stoma is required. The patient excretes urine with bowel movements, and bowel incontinence may result.
-sigmoidostomies
divert urine into a surgically created pouch, or pocket, that functions as a bladder. The stoma is continent, and the patient removes urine by regular self-catheterization.
ileal reservoir (Kock’s pouch)
Pt presenting symptoms of: Confusion, Decreased alertness, Decreased or no urine production, Dry mouth, Fast pulse, Fatigue, Pale skin color, Swelling, Thirst
Prerenal azotemia
increased level of BUN & creatine wastes in the blood
Caused by: burns, hemmoraging blood, long term N&V, decreased blood volume (dehydration)
:hypotension, tachycardia, Decreased CO, decreased CVP, decreased urine output
Azotemia
The appearance of a patient with prerenal azotemia is similar to that of a patient with what?
Heart failure or dehydration
usually occurs with damage to the glomeruli, interstitial tissue, or tubules of kidney
Intrarenal (intrinsic) AKI
A client in uremia will have all of the following except which of the following?
a. uremic halitosis or stomatitis
b. hiccups and anorexia
c. spider hemangiomas
d. nausea and vomiting
c. spider hemangiomas
this type of kidney disease is irreversible, you treat with dialysis, usually anemia, 5 stages
chronic kidney disease
advantages of using peritoneal dialysis instead of hemodialysis
- easy to learn
- ban be done at home
- ambulatory - no machine needed
a decrease in specific gravity occurs with:
increased fluid intake, diuretic drugs, and diabetes
increased specific gravity occurs with:
- dehydrartion
- decreased kidney blood flow
- the presence of ADH
- damaged kidneys absorb less water
**urine is more concentrated
normal range for glucose in urinalysis
<0.5 g/day
presence reflects hyperglycemia or a decrease in the renal threshold for glucose
normal range of pH in urine analysis
4-6.8 (less than 7 is acidic)
can be changed by diet, drugs, infection, freshness of specimen, acid-base imbalance, and altered renal functions
normal range for ketones in urinalysis
none; presencre reflects incomplete metabolism of fatty acids, as in diabetic ketoacidosis, prolonged fasting, anorexia nervosa
normal range for protein in urinalysis
0.8mg/dL; increased amounts may indicate stress, infection, recent strenous exercise, or glomerular disorders
normal range of bilirubin in urinalysis
none; presenve suggests liver or biliary disease or obstruction
normal range of RBCs in urinalysis
0-2; increased are normal with catheterization or menses but may reflect tumor, stones, trauma, glomerular disorders, cytitis, or bleeding disorders
normal range of WBCs
0-5; increased amounts may indicate an infection or inflammation in renal/urinary tract, transplant rejection, fever, or exercise
normal range of casts in urinalysis
a few or none; increased indicate presence of bacteria or protein, severe kidney disease, urinary calculi
normal range for crystals in urinalysis
none; presence states specimen has been allowed to stand
presence of nitrites in urine
suggests e coli
diagnostic test that can determine how well the bladder wall (detrusor) muscle funtions and how sensitive it is to stretching as the bladder fills. Provides information about bladder capacity, bladder pressure, and voiding reflexes.
Cystometrography (CMG)
how is Cystometography (CMG) performed
- pt voids (amt, rate of flow, and time of voiding recorded)
- catheter with cystometer is inserted to measure residual volume
- note when pt feels first feeling to void, then strong feeling
- pt voids, residual volume note, remove catheter
*infection prevention
Diagnostic test that can provide information about the nature of urinary incontinence or urinary retention
urethral pressure profile
Urinary pressure profile procedure
a special catheter with pressure-sensing capabilites is inserted into the bladder, records muscle variations as it is withdrawn
diagnostic test used to evaluate pelvic muscle strength and the effectiveness of pelvic muscles in stopping the flow of urine, useful in assessing urinary incontinence
urine stream testing
how is urine stream testing done?
patient is asked to begin urinating, after 3-5seconds the examiner gives patient signal to stop the flow of urine. Length of time required to stop flow is recorded
diagnostic test used to test the strength of the perineal muscles in voiding by placing electrodes in either rectum or urethra; used to identify methods of improving continence
electromyography (EMG)
invasive procedure done to help determine a cause of unexplained kidney problems. done percutaneously using ultrasound or CT guidance.
Kidney biopsy
Needed before kidney biopsy is performed
- consent form
- NPO 4-6h
- coagulation tests (risk for bleeding)
After kidney biopsy is completed what do you monitor for?
- Risk for bleeding (urine output. h&h)
- internal bleed (flank pain, decrease bp, decrease urine output, hypovolemia)
- microscopic blood in urine is normal for first 72h-2wk, no clots
- if bleeding from site occurs apply pressure
normal range for urine osmolarity
300-900
non-invasive method of estimating bladder volume
bladder scanner
imaging; a plain film of the abdomen is obtained, no specific pt prep, shows gross anatomic features and obvious sones, strictures, calcifications, or obstructions in the urinary tract, identifies shape and size, structural or functional problems
Kidney, Ureter, and Bladder X-rays
Assessing the patient about to undergo a diagnostic test or interventional procedure using contrast medium; before procedure ask:
- allergy to contrast (asthma pts more at risk for allergy) if yes what was reaction
- allergy to seafood eggs, milk, chocolate (reaction reported in 15% of these pts)
- allergy to shellfish, iodine
- assess for history of kiney impairment or conditions that put them at risk for contrast related nephrotocity
- have you taken metformin within 48h (causes lactic acidosis)
- hydration status (bp, mucous membranes, skin turgor, urine concentration)
- when did you last eat or drink something
conditions that have been implicated in increasing the chance of developing kidney failure after contrast media
- diabetic nephropathy
- class IV heart failure (discomfort at rest)
- dehydration
- concomitant use of aminoglycosides, NSAIDs
- cirrhosis (scarring of liver)
Prep for Computed Tomography (CT)
- pt may be NPO (specific to orders)
- dye may be given (sometimes omitted; risk for contrast-induced AKI
After undergoing procedure that uses dye monitor for:
- urine output
- push fluids
cysto-
bladder
-graphy
technique of providing images
Prep for a pt undergoing Cystography and Cystourethrograpy(images done while voiding)
- dye will be injected via urinary catheter to enhance xray
- encourage fluids
Prep for a Renography (kidney scan)
- radionuclide (no danger) will be injected IV
- may use captopril (antihypertensive) to change blood flow to kiney
- monitor for hypotension
Prep for Ultrasonography
- requires full bladder
- pt will lie prone with sonographic gel on back and flank areas
- skin care after procedure
allows dye to enter the renal blood vessels and generates images to determine blood vessel size and abnormalities; rarely used anymore use CT or ultrasonography instead)
Renal Arteriography (Angiography)
Prep for cystoscopy and cysteourethroscopy
(diagnosis [trauma] or treatment[remove bladder tumors or enlarged prostate])
- preop prep & signed consent
- general or local anesthesia will be used
- monitor post anesthesia in postop
- NPO after midnight night before procedure
- bowel prep
- foley might be put in after
going against the normal flow of urine
retrograde
Retrograde procedures prep (same as cystoscopy)
- catheters will be placed into ureter, renal pelvis, bladder or urethra
- catheters are removed and x-rays are taken to outline structures as the dye is excreted
- contrast dye is used
what causes AKI?
conditions that reduce blood flow to kineys
reduced blood flow to the kidneys causes this
prerenal AKI
obstruction of urine flow causes this
postrenal AKI
Formation of stones involves three conditions:
- slow urine flow
- damage to the lining of the urinary tract
- decreased amts of ihibitor substances
(ph abnormality, some drugs like triamterene, indinavir, and acetazolamide)
type of abdominal pain commonly caused by kidney stones
renal colic
this type of pain suggests that the stone is in the kidney or upper ureter
flank pain
flank pain that extends toward the abdomen or to the scrotum and testes of the vulva suggests stones are where?
ureters or bladder
*pain is most intense when the stone is moving or when the ureter is obstructed
What urinalysis labs may be effected by a stone?
- RBCs may be present (stone-induced trauma)
- WBCs (urinary stasis) (serum WBC = infection)
- turbidity and odor (infection)
- crystals
- PH
What diagnostic tests should you expect to be drawn when stone formation is suspected?
*confirm presence and location
- KUB
- IV urogram
- CT (maybe noncontrast)
Primary Intervention in patients with kidney stones?
- pain management
- prevention of infection (antibiotic)
- urinary obstruction (3L/day fluid intake, monitor I&O)
- nutrition monitoring (*hyper protocols)
- strain urine
lithotripsy - use of sound, laser, or dry shock waves to break up stone - PREP
- requires moderate sedation
- supine
- monitor ECG
- strain urine
- monitor bruising
What disorders disqualify a patient for a kidney transplant?
correct correctable before transplant
ucorrectable cardiac disease, metastatic cancer (2-5yrs eradicated from cancer become elgible) chronic infection, alcoholism, chemical dependency
risky for long standing pulmonary disease, diseases of GI
Criteria for organ donors: (kidney)
- 18-75yo
- absence of systemic disease and infection
- no history of cancer
- no htn or kidney disease
- adequate kidney function, determined by labs
- living or notliving (preserved)
- same blood type
Kidney donor PREP
- dialysis within 24h of surgery
- blood usually transfused into recipient
- prepared for the pain that is forthcoming (more than recipient will have)
- will take 4-5h
*
Kidney recipient postop
- postop large bore foley will be placed for accurate reading of I&O
- will be at risk for rejection, AKI, thrombosis, or obstruction
- new kidney will be placed in the R or L anterior iliac fossa
- daily weights
- oliguria or diuresis (serious problem after 3-7days)
most common type of rejection with kidney transplants, treated with increased immunosuppressive therapy and can be reversible
acute rejection
can occur after surgery as a result of hypoxic damage when transplantation is delayed after kidneys have been harvested. Hard to distinguish from acute rejection.
Acute Tubular Necrosis (ATN)
potential complication of renal transplant. characterized as a sudden decrease in urine output 2-3 days after transplant.
thrombosis of the major renal blood vessel
a patient that just received a renal transplant now has hypertension. what might be wrong?
renal artery stenosis
*may hear a bruit over the artery anastomosis site and drecreased kidney function
what may a physician do to treat a patient with a renal artery stenosis?
balloon angioplasty
Patient received a transplant within the last 48h, and now has an increased temp, bp, and pain at transplant site. what could be going on, what treatment happens next?
hyperacute rejection; immediate removal of the transplanted kidney
Patient received a transplant within the last 2wks, and now has oliguria/anuria, temp>100 inreasted bp, enlarged kidney, lathargic, elevated creatinine, BUN, potassium. what could be going on, what treatment happens next?
acute rejection; increased doses of immuosuppressive drugs
Patient received a transplant months to years ago, and now has a gradually increasing BUN and creatinine, fluid retention, electrolyte changes, and fatigue. what could be going on, what treatment happens next?
chronic rejection; conservative management until dialysis is required.
Works on principles of diffusion and osmosis
• Composition of dialysate determines solutes removed
• Osmolality of dialysate determines amount of fluid removed
• Dialysis machine contains semi-permeable membrane (artificial kidney/dialyzer)
Hemodialysis
Works on principles of diffusion and osmosis
• Composition of dialysate determines solutes removed
• Osmolality of dialysate determines amount of fluid removed
• Peritoneum acts as semi-permeable membrane
Peritoneal Dialysis
Most work on principle of hydrostatic pressure
• Pressure inside of system forces water and solutes out (into effluent)
Hemofiltration
type of hemofiltration that does use dialysate
CAVHD
type of hemofiltration that does use dialysate solution
CAVH CVVH
Where does the pressure difference come from when using CAVH?
arterial and venous systems generated hydrostatic pressure (requires MAP of at least 60mm Hg)
How is hydrostatic pressure generated when performing CVVH?
through pump (only venous catheter)
Is heparin required for hemodialysis?
yes, risk of bleed
Is heparin required for Peritoneal Dialysis?
Heparin not required intraperitoneal heparin may be needed, but is not systemically absorbed
Is heparin required for hemofiltration?
yes, Heparin required – risk of bleeding
(lower dose for CVVH than for CAVH)
How often is dialysis performed?
Typically 3 days per week for 4 hours at a time (12 hours weekly)
How often is peritoneal dialysis performed?
Timing dependent upon type but all have 3 stages (that make up an exchange)
• Infusion/fill (Typically 1-2 liters infused by gravity over 10-20 minutes)
• Dwell – physician prescribes time dialysate to be left in abdomen
• Outflow/drain – Effluent drains by gravity
how often is hemofiltration performed?
Slow and continuous
12-24 hours a day
What access points are used for hemodilation?
• HD catheters – maintained by dialysis nurse and not to be used for other purposes
• AV fistulas(shunt) connect artery to vein.
-Palpate thrill, auscultate bruit to assess patency
-Do not take B/P or draw blood from arm with shunt
How do you access peritoneal dialysis?
PD Catheter surgically inserted in peritoneum.
How do you access CAVH for Hemofiltration?
both arterial and venous catheters
How do you access CVVH for Hemofiltration?
double or triple lumen central catheter (subclavian or internal jugular; femoral site has higher infection rate)
Complications of Hemodialysis:
- Disequalibrium Syndrome (rapid fluid shifts and drop in BUN results in cerebral edema)
- Hypotension r/t removal of fluid
- Bleeding r/t use of anticoagulants (Protamine sulfate is antidote for heparin)
Primary complications of Peritoneal Dialysis:
- Abdominal pain – warming dialysate decreases discomfort
- Infection (peritonitis) – effluent will be cloudy. Strict asepsis required.
- Bowel perforation – effluent will be brown
- Constipation can result flow problems so need to manage/prevent
- Fibrin clot can form restricting outflow; “milking” tubing may dislodge clot
Primary complications for hemofiltration:
- Bleeding r/t use of anticoagulants (Protamine sulfate is antidote for heparin)
- Better tolerated than HD by patients who are hemodynamically unstable
