Urinary System Flashcards
Tests you should know about
Urinalysis/urine culture
BUN (10-20 mg/dl)
Creatinine (0.6-1.5)
Normal BUN/creatinine ratio is 10:1
KUB: Kidney-ureter-bladder x-ray, no contrast, may need bowel prep., painless
CT scans: masses, metastasis, lymphadenopathy
MRI-more sensitive in differentiating cysts vs. neoplasms
More Tests: IVPs
Intravenous pyelogram (IVP)-uses contrast medium, evaluates the entire urinary tract
Pre-procedure: assess for iodine allergies (steroids can prevent this, antihistamines), assess creatinine, bowel preparation is mandatory by 6 pm the night before the test, NPO after midnight, salty or metallic taste with dye injection
Post-procedure: hydrate to flush dye, monitor for allergic reaction if patient is sensitive
Mucomyst for iodine clearance, po liquid
More Tests:
Renal angiograms: uses contrast to evaluate renal and pelvic arteries primarily used to diagnose: RENAL ARTERY STENOSIS
Ultrasound: masses
Scopes: direct visualization, cystoscopy, nephroscopy
Cystograms-check for voiding patterns
Bladder Cancer
Risk factors: smoking, exposure to dyes, asbestos, aromatic amines, artificial sweeteners, chronic cystitis, PID
Highly treatable if tumor is superficial
Most common sign: PAINLESS HEMATURIA
Treatment for Bladder Cancer
Chemo (directly into the bladder) and radiation (not as effective but used with advanced cancer)
Urethral transection
Partial cystectomy
Radical cystectomy with urinary diversion
2 Ways to Divert Urine Through Surgical Intervention
Ileal Conduit
Part of the intestine is used to connect the ureters to a stoma, MUCOUS SHREDS ARE NORMAL, artificial pouch or bag is outside the body, urine may look cloudy
monitor stoma appearance, how should it look?
Nursing diagnosis: Disturbed Body Image
Review Ileal Conduit Image
Review ileal Conduit Images
Another Urinary Diversion
Indiana pouch, Florida Pouch, Kock pouch
Reservoir created by using ascending colon and terminal ileum, ureters are diverted to the pouch, connection to the abdomen
PATIENTS MUST SELF-CATHETERIZE THIS EVERY 3-4 HOURS
Nursing diagnosis: Disturbed Body Image
Review Image of Indiana, Kock Pouch
Review Image
Urinary/Renal Caliculi
Caused by renal stasis, stone formation (usually calcium, sometimes oxalate, uric acid, struvite)
Men more than women
More common among European, Asian descent
Common in the southeast (stone belt), northern Ohio is somewhat of a stone belt
Stone Formers
Urinary stasis Long history of calculi High mineral content in drinking water Diet high in purines, oxaltes, calcium supplements, animal proteins UTIs, foleys, neurogenic bladder Female genital mutilation
Foods High in Purines-Lead to Uric Acid Stones
Beef Pork, bacon Lamb Seafood Foods made with high amounts of yeast Beer, breads, wines
Foods High in Oxalates
Plant foods, very little in animal foods Beans, beets Beer, alcohol Teas with long brew time (5 min) Berries, grapes, kiwi, citrus, tomatoes,most fruits Chocolate Soy products Whole wheat flour
Assessment of Calculi
Subjective:
- Pain which is sharp, sudden and severe, low back, radiates
- Renal Colic vs. ureteral colic
- N/V
- Sweating
- Anxiety
- UTI’s with urinary retention
Assessment of Calculi
Objective:
- Hypertension and tachycardia
- Elevated temperature
- Elevated WBC
- Pink urine/hematuria
- KUB standard diagnostic test
Treatment of Calculi
Increase fluids: 3-4 L/day with half of that being water
Reduce pain: narcotics, antispasmodics (Ditropan)
Dietary changes: Calcium? Yes, have it. But with oxalate, decrease: tea, tomatoes, colas, rhubarb, chocolate, citrus fruits. With uric acid: low purines, no aged cheese, wine, bony fish, organ meats
Medications
Calcium: thiazide diuretics
Calcium oxalate stones: Vit. B, magnesium oxide, cholestyramine, allopurinol (Zyloprim)
Uric acid stones: allopurinal
Lithotripsy: stones are fragmented with electrical charges
Things you should know before you graduate:
Before calling the doctor for a low urine output, assess for distension, irrigate the foley and maybe even change the foley, do bladder scan
The difficulty of putting foleys in men-difficulty with the long urethral canal! When can you inflate the balloon?
What about BPH?
Stabilize the foley with tape or commercial products
What antibiotic for TB causes urine to be orange?
Urine output should be how much per hour?
Diabetes and the Kidneys
Diabetic nephropathy-leads to renal failure
Type 1 and type 2
Nephrons are destroyed, glomerulus scars leading to renal insufficiency
The best indicator for assessing for nephropathy is: microalbuminuria
When the patient starts spilling protein, even in small amounts, the patient is more likely to go into renal failure in 5-10 years
Rhabdomyolysis
Caused by traumatic skeletal muscle trauma
Also caused by: strenuous exercise, seizures, heat stroke, prolonged coma, statin use
Myoglobin released- toxic to the renal tubules (need to draw serum myoglobins to assess) causes urine to have a brown color
Can lead to acute renal failure or chronic
Treat with fluids initially to flush out myoglobin
If kidneys fail: dialysis, monitor electrolytes and fluid balance
Check up………..
Describe teaching interventions for women to prevent UTI…………
Pre and post-procedure care for IVPs include………
Interventions for UTI treatment include……
The leading risk factor for bladder cancer is………
T/F Mucous shreds indicate infection in a patient with an illeal conduit
A urostomy stoma should appear…………
Patient with uric acid stones should reduce the amount of _________ in their diet (what foods then?)
Interventions to manage renal stones include………..
The best laboratory test to monitor kidney function in the diabetic patient is…………
Rhabdomyolosis is caused by the release of _________ into the bloodstream
Urinary Incontinence
Stress Incontinence: occurs as a result if increased intra-abdominal pressure, sneezing, laughing, post-obstetric and beyond
Urge incontinence- involuntary urination with very little warning….gotta go, post-menopause, MS, Parkinson’s
Overflow incontinence- involuntary loss associated with bladder distention-BPH, narcotics, antihistamines, ETOH
Urinary Incontience Treatment:
Kegel exercises Bladder training Careful regulation of fluid intake Electrical stimulation (TENS) Artificial Urinary Sphincter Medications: Ditropan (anticholinergic agents)
Ditropan (Oxybutynin Chloride)
Anticholinergic
Exerts antispasmotic effects by inhibiting effect of acetylcholine on urinary smooth muscle- stimulation
Contraindications- glaucoma, MG, GI obstruction
SE- mydriasis, dry mouth, urinary retention, drowsiness
Benign Prostatic Hypertrophy (BPH)
Risk factors: poorly understood
Prevalence increases in men as they age
¼ men will have symptoms of: difficulty starting, stopping urine, incontinence, retention, UTIs
PSA testing annually at age 50 and then every year for men with at least 10 year life expectancy
Normal PSA is <4 ng/dl
“All men will develop prostate CA if they live long enough”
Would we test PSA if the patient is 85 and in poor health?
Prostatic CA has a slow metastatic rate
Flomax, Proscar
Flomax (tmsulosin HCL)
Alpha adrenergic receptor antagonist causing relaxation of the smooth muscles of prostate and bladder
Contraindications- women, children, lactation
SE- H/A, dizziness, decreased libido, orthostatic hypotension, nasal congestion
Women and children should not handle
Glomerulonephritis: Nephrotic Syndrome
Protein wasting (in urine) due to glomerular damage
Edema
From insufficient protein, so osmotic shift of fluid
Renin/aldosterone stimulation from low vascular volume- leads to more water retention
Glomerulonephritis: Nephritic Syndrome
Inflammation, glomeruli fail
Hematuria, urine volume, edema
B/P or BUN or GFR
Acute Renal Failure
AKA Uremia/Uremic Syndrome
Mortality rate 50% esp. after surgery or trauma
Initially UO adequate, but toxins not well-filtered
Oliguria defined as 100-400 ml/day
Anuria defined as 100 ml/day or less
Abrupt loss of kidney function over hours or days
Increased BUN/creatinine/decreased UO
Adults need to urinate at least 400 ml/day to secrete enough waste products
Classifications of ARF
Prerenal-anything that impairs renal perfusion, shock, blood volume shifts, decreased cardiac output, vascular obstruction, hypotension, hypovolemia Intrarenal-damage to the renal tubules from nephrotoxic agents, glomerulonephritis, rhabdomyolosis. Post-renal-obstruction of the urine flow, enlarged prostate, stones, tumors Non-oliguric ARF: urine is dilute, filtering is not done, but fluid loss can be great, so BUN/Creatinine are elevated BUT hypokalemia is a risk- why? Oliguric ARF (100-400 cc urine/day)-higher morbidity and mortality, mimics CRF in terms of e-lyte imbalances, fluid volume overload
Nephrotoxic Drugs
Aminogycocides- gentamycin & garamycin Sulfonamides- often used in children Rifampin- side effect?? Acyclovir- Zovirax Quinalones- ciprofloxacin (Cipro), levofloxacin (levoquin)
Treatment for ARF
Maintain F/E balance: I/O, weight, electrolytes, ECG, acid-base balance
Dialysis
Prevent Secondary Infection: leading cause of death
Maintain Nutrition-high calorie, low protein- why?
Medications and ARF
Diuretics in the early phase (otherwise, they don’t help)
Sodium bicarbonate for metabolic acidosis (kidneys retain hydrogen ions) HCO3 low
Kaexylate for hyperkalemia-PO, NG or rectal, both routes is best
Insulin (regular insulin IV push) along with 50% dextrose, insulin to drive K+ into cells, dextrose to prevent hypoglycemia
Antihypertensives
Antibiotics-avoid nephrotoxic agents, reduce the dose if possible
ARF and Dialysis
Hemodialysis is often done with temporary catheters inserted into the subclavian artery/vein IF patient tolerates it, if not other methods of fluid removal are used
ARF and Dialysis
Many patients in ARF can’t tolerate the rapid fluid removals so fluid must be removed more slowly and continuously, this is called Continuous Renal Replacement Therapy (CRRT) and there are several types
Continuous Venous-Venous hemodialysis (CVVHD):
temporary catheters placed in two veins, blood is drained from one venous access port, cleaned (through a standard dialysis filter and machines) and returned to another venous access port continuously (24/7), patients need at least a systolic pressure of 80 or system clots off, used most often
Continuous arterio-venous dialysis (CAVHD):
artery and vein are used to drain, clean and return blood through dialysis filter and machines (need a systolic BP of at least 90 or will clot off)
Chronic Renal Failure (CRF):
DM and hypertension are the leading causes of CRF, but also ARF, nephrotoxins, glomerulonephritis
Azotemia- elevated BUN/creatinine
Reduced renal reserve: BUN is high-normal but no clinical manifestations of renal failure
Renal insufficiency: Mildly elevated BUN/creatinine, mildly anemic, renal function affected by stress on body
Renal failure-acidosis, severe anemia, e-lyte imbalances, impaired urine dilution
ESRD (end-stage renal disease)-kidneys are totally shut down and contribute nothing to homeostasis
Systemic Changes from CRF:
Electrolyte Imbalances-sodium retention, hyperkalemia, hypocalcemia, hyperphosphatemia, lower phosphate with Renagel (there are others)
Osteomalacia- Vit D deficiency causing softening/brittle bones and bone pain
Metabolic changes: impaired insulin production or metabolism, elevated triglycerides- liver makes more lipids
Metabolic acidosis- kidneys can’t excrete H2 Ions
Hematologic: anemia (decreased erythropoetin production in kidneys)
GI: N/V, bitter, metallic or salty taste, increased secretion of gastrin (More acid=more ulcers)
Renagel (sevelamer HCL)
Normal phosphate level 2.4 - 4.1 mg/dL
High phosphate leads to calcification of kidney tissues, hypocalcemia
Renagel binds to intestinal phosphates, so need functioning GI tract
Should be taken alone- give other meds 1 hr before or 3 hrs after Renagel
Systemic Changes Cont:
Immune system: decreased function= more infections, decreased lymphocyte action
Changes in medication metabolism
CV: volume overload, hypertension, stimulation of RAAS
Pulmonary- edema
Skin: dry due to atrophy of sweat glands, pruritus, purpura, petechiae, bruising, pallor, grayness due to pigment changes, brittle hair and nails
Reproductive: menstrual irregularities, pregnancy is still possible, low sperm counts
Psychosocial: stress, powerlessness, body image changes, role strain, financial strain
Medical Management
Preserve renal function (control blood pressure, reduce protein intake)
Epogen/procrit-medication that stimulates RBC production by the bone marrow
Phosphate binding agents: Renagel: high PO4 causes low CA, these drugs bind phosphate
Supplemental iron
Dialysis
Transplant
Peritoneal Dialysis (PD):
Less precise than HD, but useful for those who do not tolerate HD or can’t maintain a shunt
Dialysate is instilled via a catheter into peritoneum, allowing for electrolyte exchange while retained (dwell time) then removed, wastes are removed through the outflow, CRF and ARF
Contraindications: scarring or adhesions in the peritoneal cavity, obesity, failure of PD to clear toxins, abdominal malignancies, extensive abdominal surgeries, peritonitis
Continuous ambulatory peritoneal dialysis (CAPD) four dialysis cycles every 24 hours with 8 hour dwell overnight
Peritoneal Dialysis cont:
No machines, no electricity needed
Insulin can be added to the dialysate
Warmed dialysate is placed by gravity, usually 2 L, prevent air from entering
Dwell times during the day: 30-45 minutes to several hours, maximum exchange occurs in the first five minutes
Fluid runs out by gravity
Peritoneal Dialysis Complications
Peritonitis: fever, rebound abd. tenderness, elevated WBC
Prevent with aseptic technique with exchanges
Treat: antibiotics orally and/or instill into dialysate
Catheter complications: kinking/obstruction
Bowel perforation: fecal material in the dialysate
Dialysate problems: too rapid infusion of dialysate (slow down instillation), hypotension due to too rapid removal, hyperglycemia
Successful for many years unless repeated bouts of peritonitis
Hemodialysis (HD):
ARF or CRF
Blood is cleaned using a pump and exposed to dialysate fluid to draw out waste
Functional access device is a must and has many nursing considerations….stay tuned
Arterial blood is cleaned first and then blood is returned to the venous side
3-4 hours of treatment 3 days a week
MDs/NPs prescribe the amount of weight loss goal according to the patient’s “dry weight”
Dialysis is done by RNs, dialysis techs
HD access devices:
Internal arteriovenous fistula is the preferred device.
Surgical procedure where artery in the arm is anastomosed (sewn together) to a vein in the arm
Takes six weeks to a mature, so HD can’t be done but PD can
Artificial AV fistulas with Gore-Tex graft or bovine arteries for patients who don’t have adequate blood vessels OR patients who have lost previous “natural grafts”, takes two weeks to mature
Temporary devices include the double lumen catheter inserted into the subclavian (Quinton catheter)
ALL DEVICES,WHETHER ARTIFICIAL OR PATIENTS OWN DEVICES MUST BE ASSESSED DAILY FOR A BRUIT AND A THRILL
Review the images of HD
Review the images of HD
Complications of HD
Clotting, infection, aneurysms of the graft
Technical problems: leaks, improper dialysate solution, etc.
Hypotension/hypertension
Cardiac dysrhythmias r/t e-lyte imbalances
Air embolus
Hemorrhage
Infection-Hepatitis B, endocarditis
Dialysis Disequilibrium syndrome: esp. during first few days of dialysis, mental confusion, decreased LOC, headache, seizures, may last several days- new dialysis patients will have slower flow rates and shorter times
CRF and Diet: More Considerations
Alteration in Nutrition
Decreased protein: 1.2 grams of protein for HD patients per day, 1.3 grams of protein for PD patients per day
N/V, anorexia
Dietary consult
Nursing Diagnosis for CRF/ARF:
Fluid volume excess/deficit Constipation Fatigue Risk for Infection Risk for Injury (hemorrhage, e-lyte imbalances, Disequilibrium Syndrome) Risk for impaired skin integrity Ineffective Therapeutic Regime: COMPLIANCE with treatments, meds, fluid restrictions, diets Ineffective individual coping
Check up………………………..
The most common causes of prerenal ARF include………
Define oliguria
How does CRF affect the body systemically?
Describe dietary changes for patients with ARF,CRF
The complications of PD include……….
Complications of HD include…………..
Renagel (and drugs like it) are used to………..
