Week 11 Flashcards
Renal function helps…
Renal function helps maintain the body’s state of homeostasis
The function of renal and urinary systems is
Regulating fluid and electrolytes (excretion/re-absorption): Fluid balance Acid-base balance Electrolyte balance Removing wastes
Providing hormones: Red blood cell production Erythropoietin Bone metabolism Assists in conversion of Vitamin D to maintain calcium balance Blood pressure regulation Renin/Prostaglandins
Subjective data - patient assessment
Past medical history and pre-existing conditions: (Diabetes/hypertension/calculi/childbirth/STDs)
Medications (allergies):
potentially nephrotoxic (gentamycin/captopril/NSAIDs/aspirin)
others change urine colour (nitrofurantoin/dantrolene)
increase urine output (diuretics)
alter sphincter function/bladder contraction (Ca. channel blockers/antidepressants/antihistamines)
haematuria (anticoagulants)
Past surgical history/treatments – related to this system
Functional health pattern questions:
Changes in voiding habits/haematuria/pain (dysuria)
Family history
Objective data - patient assessment
Physical examination:
Especially abdominal and kidney palpation
Presence of oedema
Bladder percussion
Digital (rectal) prostatic palpation (DRE)
Inspection of genitalia/urinary meatus
Abnormal anatomy (female circumcision/”whistle-cock”)
Diagnostic tests for renal and urinary system
Urinalysis - baseline information – 1st am spec.
24 hr urine collection - creatinine/protein/specific components
Empty bladder at designated time
MSU/catheter spec.
Residual urine – left in bladder after urination (< 50-150mls)
Blood tests – specifically creatinine & urea
Radiological – x-rays/IVP/ultrasound/CT Scan/MRI/’scopes
Radionuclide Imaging/biopsy/cystoscopy
Renal function tests
Patient preparation
? Full bladder/? Encourage fluids/? fasting
The prostate gland
encircles the urethra just below the neck of the bladder
Benign prostatic hyperplasia (BPH)
Proliferation of cells leading to increase in gland size
Occurs in 50% of men over 50 yrs/90% of men over 80 yrs/etc
Depending on lobe affected can gradually compress (and obstruct) urethra
Prostate cancer
Malignant tumour affecting 1 in 11 Australian men/kills 20-25% of those diagnosed
Earlier detection leads to better/more successful treatment
Can lead to urinary retention/obstruction
Frequently diagnosed by pain/fracture after it metastasises
Clinical manifestations of benign prostatic hyperplasia
Mild to severe Mild weakening of urinary stream Frequency Hesitancy Dribbling Incomplete bladder emptying Retention Nocturia Urgency Dysuria Incontinence
Treatment of benign prostatic hyperplasia
Depends on severity of symptoms/age & condition of pt.
Conservative
“watchful waiting”/dietary changes/bladder training
Medication
anti-androgenics (finasteride)/alpha adrenergic agonists (prazosin)
Surgical : Microwave thermotherapy/needle ablation Laser prostatectomy/electrovaporisation Transurethral resection prostate (TURP) – most common (open) radical prostatectomy
Urinary retention is
Inability of the bladder to empty completely
types: chronic or acute
Residual urine is the
Amount of urine left in the bladder after voiding
Generally 100/150 mLs on 1/2/3 occasions
Assessment of urinary retention
Subjective – feel “empty” or “full”/dysuria/previous problem
Objective – pt. dribbling/monitor output (“fluid balance”)distension /palpation/percussion/pt. restless or agitated/bladder scan
Nursing measures to promote voiding
Set environment (privacy)/running water /baths/warm compresses Catheterisation may be necessary to prevent bladder overdistension
Benign prostatic hyperplasia common surgery is
Trans Urethral Resection of Prostate (TURP)
Under general or spinal anaesthetic
From 15 mins to 2-3 hours depending on size of prostate
Complications minimal (haemorrhage/hyponatraemia/infection)
Post-op - large bore 3 way catheter/bladder washout (BWO)
Nursing management for Trans urethral resection of prostate
Preop - ? retention - IDC/UTI – antibiotics/education
Postop
Bladder Washout
Accurate monitoring and measurement of input/output essential
Urinary tract infections are classified according to
Lower tract – urethritis/cystitis/prostatitis (dysuria/generally unwell)
Upper – pyelonephritis/interstitial nephritis/renal abscess
Complicated (IDC/obstruction/stone/pregnancy/recurrent)
Uncomplicated – in otherwise normal tract
Initial or recurrent
Unresolved or persistent
Bacteria type
Urinary tract sterility is maintained by
Complete emptying of bladder Antibacterial capabilities of mucosa Peristaltic actions of urethra Vesico-ureteric competence (valve/trigone angle/musculature) Urine acidity (<6.0) and flow
Predisposing factors for UTI
Obstruction (stone/stricture/BPH)
Urinary retention/incomplete bladder emptying (high ‘residuals’)
Foreign objects (catheterisation/stents)
Sex/age/immunological/pregnancy/hormonal/hygiene/anatomical
Immunosuppression
Co-morbidities
UTI diagnosis
Via urine dipstick test(indication not diagnostic)
MSU
Clinical manifestations
UTI - lower urinary tract clinical manifestations
Dysuria Frequency Urgency Nocturia Weak stream Dribbling Hesitancy Intermittency Incomplete emptying of bladder Haematuria
UTI - upper urinary tract clinical manifestations
Dysuria Frequency Urgency Nocturia Weak stream Dribbling Hesitancy Intermittency Incomplete emptying of bladder Haematuria Abdominal/flank/supra-pubic pain Vomiting/diarrhoea Fever/chills Confusion General malaise
UTI - upper and lower urinary tract in older patients clinical manifestations
Confusion/lethargy
Frequency/urgency/dysuria
Anorexia
Low grade febrile episodes
Prevention of UTI
Avoid indwelling catheters, aseptic insertion & hygienic care of catheters
Personal hygiene
Void after sex/wipe front to back
Medications as prescribed:
Antibiotics, analgesics, and antispasmodics
Increased fluid intake
Avoid urinary tract irritants such as coffee/tea/citrus/spices/ cola/alcohol
Frequent voiding/reduce urine retention
? Prophylactic cranberry juice
Patient education
Treatment of UTI
Antibiotics
Recurrent UTIs: Prophylactic antibiotics Investigate abnormalities/treat cause Cranberry juice(?) Patient education
Renal failure is
partial or complete kidney dysfunction
Leads to accumulation of metabolic wastes
Leads to alteration in fluid/electrolyte and acid-base balance
Acute renal failure
Rapid loss of renal function (hours or days)
Decreased GFR & ? oliguria
Reversible (potentially) but high mortality rate
More common in elderly
Chronic renal failure
Slow insidious and irreversible
Can have acute on chronic episodes
End-stage renal disease
Final, irreversible stage of chronic renal failure
Azotaemia is the
accumulation of nitrogenous wastes
Uraemia is
symptomatic changes in multiple body systems due to progressive azotaemia
Glomerular filtration rate
~ 100 - 120 ml/minute
Catabolism is the
breakdown of body proteins
Acute renal failure - pre renal
Factors that decrease renal blood flow:
Hypovolaemia (haemorrhage)
Dehydration/nausea & vomiting
Decreased cardiac output (heart failure/MI)
Decreased peripheral vascular resistance (septic shock)
Decreased renal blood flow (renal vein emboli)
Acute renal failure - intrarenal
Factors that cause direct damage to the renal parenchyma: Nephrotoxic injury (drugs – gentamycin/heavy metals) Infection (pyelonephritis/glomerulonephritis) Thrombosis Toxaemia (pregnancy) Malignant hypertension SLE (systemic lupus erythematosus)
Acute renal failure - post renal
Mechanical obstruction BPH Bladder cancer Renal calculi Neuromuscular disorders Prostate cancer Spinal cord diseases Strictures Trauma
Phases of acute renal failure
- Initiation phase
From time of injury to clinical manifestations evident - Oliguric (Maintenance) phase
Notable fall in GFR and tubular damage
Uraemic symptoms and oedema increase/hypertension
Confusion/fatigue/acid-base imbalance/anaemia/ECG changes (hyperkalaemia) - Diuretic (maintenance) phase
Glomeruli and tubules still dysfunctional
High urine volume/still severely uraemic with all it’s affects
Dehydration potential - Recovery Phase (3 – 12 months)
Glomerular and tubular repair and regeneration
Gradual recovery and improvement in all areas
Clinical manifestations of acute renal failure
Potentially evident in every body system
Persistent nausea & vomiting & diarrhoea
Lethargy/general malaise/fatigue
Signs of dehydration (dry mucous membranes/skin)
Uraemic fetor
CNS symptoms
Twitching/drowsiness/headache/seizures
Urine output variable according to the stage of ARF (~20mLs/hr)
ECG changes
Haematuria
Diagnosis of acute renal failure
Urinary changes/blood tests/renal function tests/scans
Treatment of acute renal failure
Detect & resolve the underlying cause
Treat the clinical manifestations & prevent complications
Nutritional support
Continuous renal replacement therapy (haemodialysis)
Used more frequently for early intervention to prevent complication and recovery
Medications:
IV fluids/volume expanders to improve renal perfusion
Diuretics to increase urine output (decrease fluid overload/washout wastes)
Antihypertensives to decrease blood pressure
NSAIDs/nephrotoxic drugs ceased
Proton-pump inhibitors/other to prevent GI haemorrhage
Calcium resonium to decrease hyperkalaemia (!)
All drug doses need to be titrated carefully as most are excreted through the kidneys
Nursing care for acute renal failure
Monitoring:
Vital signs/skin assessment (for dehydration)
Subjective & objective assessment (cardiac/pulmonary function)
Fluid balance monitoring (intake and output) - strict
Previous 24 hrs output + 600mls (insensible loss) - ???
Daily weight/regular oral hygiene
Administer drugs (& monitor for side effects)
Monitor lab. results (frequent)
General nursing care (skin)/bed rest (reduce metabolic rate)
Asepsis
Patient & family support/education
Nutritional (dietician monitored)
Balance bodily requirements with preventing fluid & electrolyte disorders
Daily kilojoules – 125-150kj/kg
Increased carbohydrates to provide energy (& spare protein)
Protein (high in essential amino acids) – 0.6-2.0g/kg (restricted)
Potassium in diet dependant on serum levels (restricted)
Sodium (restricted to decrease oedema)
Phosphate (restricted)
Enteral feeding (TPN – Total Parenteral Nutrition) if unable to eat/drink but will likely require haemodialysis to remove extra fluid Fluid balance monitoring (intake & output) – strict/daily weight
All fluid and food is measured/weighed/specially prepared
Chronic renal failure is the
Result of chronic disease processes with gradual destruction of glomerular filtration and tubular function
Can be as a result of ARF where full recovery not achieved
Chronic renal failure management
Preserve existing renal function
Preventing and managing complications
Providing psychological support
Pharmacological:
Complex as many drugs are excreted via the kidneys
Treat underlying cause of CRF and associated conditions
Manage clinical manifestations
Diuretics/antihypertensives/resonium/phosphate binders etc
Nutrition and fluid management:
Nutritional and fluid management in line with ARF
Nursing care of chronic renal failure
(Basically as per ARF)
Fluid management
Nutritional management
Full nursing care
Patient self management:
Educate and encourage
Community resources and support groups
Depends on setting – home/regional/tertiary hospital
End-stage renal failure
Requires renal replacement therapy
Haemodialysis
Peritoneal dialysis
Kidney transplantation
Either in-hospital or at home
Urinary catheterisation diagnosis
Monitoring urine output
Instillation of radio-opaque dye/medications
Obtaining specimens
Urinary catheterisation treatment
Obstruction/retention Post procedure (surgery/childbirth)
Urinary catheterisation types
Intermittent/indwelling
Insertion into bladder/ureter/kidney
Ileal diversion (bags)
Urinary catheterisation complications
Only if necessary Bladder scanners instead of residual catheters UTIs (during insertion/while inserted) Track for infection Mucosal irritation Invasive and embarrassing Bladder spasms Urethral false passage/rupture Urethral strictures Pressure necrosis Allergy (most now latex free)
Supra-pubic catheterisation
Temporary
Post surgical/Post trauma
Permanent
Urethral destruction
Patient choice (? easier care if paralysed)
Residual urine pre removal (clamp for 4 – 6 hrs/pt attempts to void then unclamp & drain.
2 x successful residual urines under 100/150 - removed)
Advantages to supra-pubic catheterisation
Comfort & mobility/less UTI/spont. voiding post removal easier
Complications of supra-pubic catheterisation
Encrustaceans/bladder stones/UTIs/presence of wound
Requires more specialised care
Nursing management of indwelling (urethral) catheter
Depends on type/indication
Monitor drainage:e
Amount/colour/odour
Fluid balance chart
Secure catheter (an issue of importance):
With traction (if ordered) for tamponade (post TURP bleeding)
Prevent urethral erosion/comfort/accidental removal/leakage
For men – abdomen or upper thigh (varying practice)
For women – upper thigh
Surgical tape or proprietary device (varies)
Monitor for infection
