Week 6: Renal disorders Flashcards

Question

Define Acute cystitis. List its; - cause - common clinical manifestations - which gender is it more common in and why? - which populations are at an increased risk of infection?

Answer 1

``` An acute (fast) inflammation of the bladder (Lower UTI) - most common site for UTI ``` Cause= most commonly caused by E.coli followed by Staphylococcus saprophyticus Clinical manifestations= urgency, frequency, dysuria, suprapublic/lower back main More common in females due to shortened urethra and closeness to anus (increased contamination for bowel bacteria) Youth (poor hygiene) and elderly (often experience delirium)

Answer 2

Pyelonephritis= acute infection of the kidney 'pyelo' means pelvis and 'neph' refers to renal - can effect both kidneys Cause: ascending bacterial infection, urinary reflux and obstructions such as kidney stones and pregnancy Complications= can lead to tubular necrosis and AKI (one or both kidneys can be involved) Clinical manifestations= flank pain on side of infection, loin pain, fever, rigours, chills, nausea and vomiting, lethargy, malaise, symptoms of cystitis Symptoms= this triad is a clear indicator: vomiting, flank pain, fever. - often misdiagnosed as appendicitis or acute abdomen

Answer 3

Hospital-acquired infections are typically nosocomial (originate in hospital) infections that aren't present at the time of admission. Risk factors= IDC's (in for longer durations and poor quality care further increase risk) Causatuve= E. coli Associated complications= cystitis, pyelonephritis, prostatitis, bacteria, orchitis and epididymitis The most preventable HAI

Answer 4

- perform hand hygiene immediately before inserting IDC - use strict a septic techniques (replace IDC when if aseptic technique is broken) - obtain urine samples via clean access port - if taking sample from urinary bag, keep bag lower then body, maintain aseptic status. - to maintain unobstructed flow od IDC bag; empty regularly, never allow the bag to get over ¾ full, use closed irrigation if obstruction is anticipated - for short term IDCs; avoid routinely changing the IDC or drainage bag. Only change if clinically indicated e.g. obstructed, break in closed circuit, infection only use an IDC for appropriate indications, not for routine use e.g. post-op, avoid use to manage incontinence minimise duration - only keep inserted for as long as clinically needed - this may vary and can be discussed with the patient's medical team secure IDC to prevent movement and trauma to the urethra use the smallest bore necessary that will ensure good drainage whilst eliminating as much trauma as possible consider alternatives e.g. use a bladder scanner to assess urine volume instead of inserting catheter always clearly document all care of IDC including date, time, need for catheterisation, insertion, gauge of IDC, amount of water used to inflate balloon, reviews, observations, drainage type, total output adopt quality-improvement strategies e.g. education, review of practices, audits

Answer 5

- inability to void voluntary - complete lack of voiding, incomplete bladder emptying and overflow incontinence. - renal failure and infection Causes = Diabetes Constipation Prostatic enlargement Urethral pathology (infection, calculi, tumour) (most common infection is acute prostatitis) Trauma/injuries Surgery - for example anorectal surgery, hernia repair, orthopaedic surgery Anaesthesia - post operative - known as postoperative urinary retention (POUR) Neurological disorders Medications Frailty and immobility

Answer 6

Acute urinary retention= the sudden and often painful inability to void despite having a full bladder. Chronic urinary retention= painless retention associated with an increased volume of residual urine.

Answer 7

- escalate to nurse in charge and medical team - PHHx questions= last time voided, void volume, recent illness or symptoms - Pain assessment - Physical assessment= (Focused assessment on abdomen and renal system) - perform bladder scan to determine volume of bladder and PVR- post void residual(nurse initiated) Most patients will require prompt management with immediate urinary catheterisation - you do not require a medical order to insert an IDC EXCEPT if the patient has significant urinary comorbidities e.g. benign prostatic hyperplasia

Answer 8

A bladder scan is a simple, non-invasive procedure that is nurse-initiated to assess the volume of urine in a patient's bladder This procedure is often performed prior to the insertion of a catheter or when you suspect your patient has urinary retention

Answer 9

a kidney disorder that involved damage/inflammation to the glomeruli (the filtration units if the kidney responsible for removing waste and toxins from blood to make urine) Cause= unknown by may be streptococcal infection of the throat/skin an immune disease, hypertension, vasculitis or viruses such as HIV or hepatitis - affects both kidneys equally - higher risk of developing GN if of Aboriginal Torres Strait Islander descent.

Answer 10

Chronic= develops gradually over time, progressive (usually results in irreversible kidney failure) Primary= if GF occurs on its own Secondary= if GN occurs in association with an immunological disorder such as diabetes or lupus

Answer 11

- kidney disease - infections e.g. post-sttreptococcal glomerulonephritis (APSGN) (most common cause, especially for children and young adults), infective endocarditis, viral infections such as tonsillitis - Systemic diseases (immunological disorders) e.g. systemic lupus erythematosus (SLE), scleroderma, Goodpasture's syndrome, IgA nephropathy - Vasculitis = polyarteritis nodosa - Conditions that cause scarring of the glomeruli = hypertension, diabetic nephropathy - Illicit drug use - Cancer

Answer 12

Symptoms usually occur 1-3 weeks after infection, can come on suddenly or be gradual, be silent, mild, moderate or severe: Foamy urine - proteinuria - Pink urine - bleeding in the upper urinary tract (infection causing pain) - Hypertension (poor filtration leading to water retention) Fluid retention - swollen hands, feet, abdomen, face (poor filtration leading to water retention) Shortness of breath Nocturia

Answer 13

Disease occurs which triggers an immunological response → deposition of immune antigen-antibody complexes or antibodies specific for glomerular basement membrane → activation of biochemical mediators of inflammation e.g. complement, cytokines → cell lysis & attraction of neutrophils, monocytes & T cells (Bowman space) → release of oxidants and lysosomal enzymes increasing inflammatory response → damage to glomerular epithelial cells & basement membrane (increases permeability & decreases glomerular membrane surface area) → decreased glomerular blood flow and GFR, decreased hydrostatic pressure, hypoxic injury, platelet aggregation → glomerular sclerosis, interstitial fibrosis and glomerular thrombosis → proteinuria, haematuria → acute kidney injury and renal failure

Answer 14

- accurate clinical history (progressive development of signs and symptoms) - urinalysis (elevated protein and erythrocytes) - Bloods= renal function= FBE, UEC, CRP - renal biopsy

Answer 15

- accurate assessment including clinical history= diagnose, guide are and ensure patient comfort - Interventions= urinalysis, vital signs, bloods, fluid balance chart, medications as per chart - Documentation (clear and accurate documentation e.g. fluid balance, vital signs, progress notes) - education and support

Answer 16

Acute - Mostly conservative management - Treat primary disease e.g. antibiotics to treat infection - Prevent & minimise immune response - Occasionally may need; antihypertensives to control blood pressure and corticosteroids to reduce inflammatory response Chronic - No treatment - Diet changes = low salt, protein and potassium - Diuretics to manage fluid retention - Antihypertensives

Answer 17

This is a clinical syndrome characterised by - sudden decline in renal function with or without a decrease in urine output (oliguria)= this inhibits kidneys ability to regulate fluid, electrolytes and acid-base balance. - it incorporates all stages from slight deterioration in function to sever impairment that occurs during renal failure. - potentially reversible but only with early diagnosis and treatment

Answer 18

a decrease in urine output

Answer 19

- rapid onset= within hours to days - Rapid loss of kidney function= 25% of normal or GFR 25-30ml/min Effects include; - azotaemia (an elevation of blood urea nitrogen (BUN) and serum creatinine levels) - uraemia (build up of toxins in the body)- symptoms exhibited - fluid imbalances - electrolytes imbalances - acid-base imbalance

Answer 20

- Trauma e.g. burns, blunt force, shearing injuries, stabbing, crush injury - Surgery - Shock e.g. sepsis, anaphylaxis - Decreased cardiac output e.g. myocardial infarction - Dehydration - Hypovolaemia, hypoxaemia, hypotension - Nephrotoxic agents e.g. drugs (some antibiotics such as gentamicin), iodinated radiocontrast agents, heavy metals - Age >70 - Comorbidities or illnesses e.g. chronic diseases of the heart, lungs and liver, diabetes mellitus, anaemia - Hospital admission - 1-5% of patient and 20-50% of all ICU patients

Answer 21

Urinary - oliguria - proteinuria - ↓ specific gravity - haematuria Cardiovascular - volume overload - congestive heart failure - hypotension (early) - hypertension (late) - arrhythmias - tachycardia Respiratory - tachypnoea - dyspnoea Integumentary - pruritus - dry skin Haematological - anaemia (develops within 48 hours) - increased susceptibility to infection - defect in platelet functioning ``` Gastrointestinal - nausea - vomiting metallic taste in mouth - anorexia - dry oral mucosa ``` ``` Metabolic ↑ urea ↑ creatinine ↓ sodium ↑ potassium ↓ pH ↓ bicarbonate ↓ calcium ↑ phosphate ``` Neurological - lethargy - seizures - memory impairment - altered conscious state

Answer 22

Prerenal AKI Intrarenal AKI Postrenal AKI

Answer 23

- Caused by conditions that decrease renal blood flow and perfusion therefore injury occurs before the kidney - can lead to intrarenal disease if renal ischaemia is prolonged - most common cause = 55-60% of all cases of AKI PATHOPHYSIOLOGY ↓ systemic blood flow → ↓renal blood flow → ↓ perfusion to kidneys → ↓ glomerular perfusion and/or filtration pressure → ↓ GFR → oliguria, ↑ serum creatinine = AKI EXAMPLES Drugs that results in renal vasoconstriction (e.g. NSAIDs) Hypoperfusion = hypotension, hypovolaemia, haemorrhage, poor cardiac output

Answer 24

Occurs due to direct damage to renal parenchyma which causes impairment to nephron function therefore direct kidney injury Most commonly caused by acute tubular necrosis (ATN) secondary to prerenal acute kidney injury (90% of intrarenal AKI cases) 2nd most common phase = 35-40% of all AKI cases PATHOPHYSIOLOGY Hypovolaemia → hypotension → ↓ renal blood flow → ↓ perfusion to kidneys → ischaemia → production oxygen-free radicals (toxins) → disruption of tubular epithelium → cell swelling, cell injury and cellular necrosis (ATN) → ↓ GFR, oliguria, ↑ serum creatinine = AKI Nephrotoxins → necrosis of tubular epithelial cells → cells slough off → tubules occlude → cell injury and cellular necrosis (ATN) → ↓ GFR, oliguria, ↑ serum creatinine = AKI EXAMPLES ``` Nephrotoxic agents (e.g. iodinated radiocontrast agents, some antibiotics such as gentamicin) Acute glomerulonephritis, sepsis Vascular disease = thrombotic disorders, prolonged renal ischaemia (up to 50% of post-op patients) Trauma = crush injury ```

Answer 25

Occurs due to a mechanical obstruction of urinary outflow resulting in reflux and impaired kidney function Always treatable if identified before permanent damage occurs Follows several hours of oliguria with lower urinary symptoms (frequency and hesitancy), with flank pain then polyuria. Least common phase → <5% of all AKI cases PATHOPHYSIOLOGY Obstruction → urine reflux into renal pelvis → ↑intraluminal pressure upstream from obstruction → kidney dilation (hydronephrosis) → ↑ hydrostatic pressure → tubular blockage →gradual ↓ GFR, oliguria, ↑ serum creatinine = AKI EXAMPLES All conditions that can cause obstruction of urine outflow e.g. prostatic hypertrophy, neurogenic bladder, bilateral ureteral obstruction or destruction from oedema, clots, stones, tumours.

Answer 26

Regardless of cause or type, AKI is progressive and follows a course characterised by 4 stages. Initiation (onset) stage Begins with the onset of event that causes ATN → ↓ perfusion and toxicity → evolving kidney injury May span several hours to 2 days Patients can be asymptomatic If AKI is recognised and interventions commenced at this stage, prevention of injury is possible and the prognosis is good The initiation phase ends when renal damage occurs Maintenance Stage Begins within hours of initiating event and can last weeks to months Renal damage well established Characterised by persistent oliguria and elevated serum creatinine & blood urea nitrogen (BUN) Necrotic cells are sloughed → tubular obstruction → ↓ GFR & urine output → inability to eliminate metabolic wastes, water, electrolytes and acids Characterised by urinary changes, azotaemia, fluid retention, neurological disorders, metabolic acidosis and electrolyte imbalances = hyponatraemia, hyperkalaemia, hypocalcaemia, hyperphosphataemia Diuretic Stage Gradual rise in urine output Nephrons not fully functioning Excretes wastes but does not make urine concentrated Risk of hypovolaemia and hypotension Normalise fluid, electrolyte and acid-base balance Recovery Stage Begins when GFR and the renal tissues repair themselves and renal function is re-established Phase may take 3 – 12 months but some patients may not have full renal function recovery Progressive ↑ in urine output Improvement in pathology results → ↓ serum creatinine & urea levels, ↑ creatinine clearance

Answer 27

Focus for health history questions: ``` new onset of dysuria changes to frequency / urgency new onset of incontinence any nocturia haematuria any comorbidities e.g. diabetes, hypertension exposure to nephrotoxins Examples of health history questions ``` Do you have any symptoms such as frequency, urgency, pain on urination, incontinence, fevers, abdominal/lower back/flank pain? Have you noticed any changes to your usual urinary function? What colour is your urine? Do you have difficulty passing urine? if so, how long has this been happening? Do you feel like you have a problem with your kidney or bladder function? How does your urine function impact your life? What is your past medical/surgical history e.g hypertension, cardiac disease, diabetes etc.

Answer 28

- Health history - physical assessment - Nursing management - medical management

Answer 29

Focus for health history questions: ``` new onset of dysuria changes to frequency / urgency new onset of incontinence any nocturia haematuria any comorbidities e.g. diabetes, hypertension exposure to nephrotoxins Examples of health history questions ``` Do you have any symptoms such as frequency, urgency, pain on urination, incontinence, fevers, abdominal/lower back/flank pain? Have you noticed any changes to your usual urinary function? What colour is your urine? Do you have difficulty passing urine? if so, how long has this been happening? Do you feel like you have a problem with your kidney or bladder function? How does your urine function impact your life? What is your past medical/surgical history e.g hypertension, cardiac disease, diabetes etc.

Answer 30

``` Nursing team accurate documentation e.g. progress notes ISBAR handover discuss concerns and progress Liaise with treating ``` medical team (documentation and verbal discussion) how often to perform venepuncture dose adjustments of medications results of diagnostics such as urinalysis and bladder scan fluid replacement requirements red flags with assessment such as changes to urine output, abnormal vital signs, met call criteria Liaise with Allied health Dietician nutritional needs electrolyte balances hydration Social worker anxiety family support home support OT home aides / support Physio exercises,pelvic floor Pharmacist discuss medications

Answer 31

*When a ureter becomes completely obstructed, a nephrostomy tube can be inserted on a temporary basis to preserve renal function. Causes of ureter obstruction include: ``` renal calculi masses of crystals, protein or other substances infection anatomical abnormalities trauma ```

Answer 32

``` Nursing team accurate documentation e.g. progress notes ISBAR handover discuss concerns and progress Liaise with treating medical team (documentation and verbal discussion) how often to perform venepuncture dose adjustments of medications results of diagnostics such as urinalysis and bladder scan fluid replacement requirements red flags with assessment such as changes to urine output, abnormal vital signs, met call criteria Liaise with Allied health Dietician nutritional needs electrolyte balances hydration Social worker anxiety family support home support OT home aides / support Physio exercises,pelvic floor Pharmacist discuss medications ```

Answer 33

*When a ureter becomes completely obstructed, a nephrostomy tube can be inserted on a temporary basis to preserve renal function. Causes of ureter obstruction include: ``` renal calculi masses of crystals, protein or other substances infection anatomical abnormalities trauma ```

Answer 34

- Regular vital signs = half hourly vital signs for 2 hours, hourly for 2 hours, then 4 hourly for 24 hours. - Pain management is essential and should be administered both prior to the procedure and regularly post-procedure. - Accurate fluid balance chart = urine measures hourly for the first 4 hours then every 4 hours for 24. - Drainage site assessment for bleeding = checked every hour for the first 4 hours, then every 4 hours for the next 24 hours - Ensure adequate hydration - the patient would have been nil by mouth for at least 6 hours prior to the procedure - Bed rest for 4 hours - Ensure drainage bag is placed below the level of the kidney at all times Inform the doctor if: - urine output drops below 30mls over 1 hour, or - urine becomes heavily blood stained (some haematuria is normal and should decrease over the first 48 hours) - patient develops abnormal vital signs e.g. temperature above 38, hypotension, tachycardia

Answer 35

- assess urine output / maintain strict fluid balance chart - monitor colour in drainage bag e.g. check for haematuria - monitor for signs of UTI e.g. vital signs - monitor for pain, inflammation, infection at drain site - wound management - assessment, dressing changes using aseptic technique - regular emptying of the drainage bag with appropriate - hand hygiene - irrigation of nephrostomy tube daily under aseptic technique - as instructed by the patient's medical team and / or as per Organisational guidelines = 2-10mls of normal saline and no more than 20mls at a time - nephrostomy tube must be connected to a sterile closed drainage system - drainage bag should be below the level of the kidneys at all times - inspect tube to ensure it is secure with no obstruction and no leakage e.g. kinked tube, sediment, leaking from connection - communicate and document all treatment, progress and concerns i.e. tube not flushing, fevers, increased pain, urine output less than 30mls per hour - encourage fluid intake - maintain adequate analgesia - education and support

Answer 36

Regular vital signs = half hourly vital signs for 2 hours, hourly for 2 hours, then 4 hourly for 24 hours. Pain management is essential and should be administered both prior to the procedure and regularly post-procedure. Accurate fluid balance chart = urine measures hourly for the first 4 hours then every 4 hours for 24. Drainage site assessment for bleeding = checked every hour for the first 4 hours, then every 4 hours for the next 24 hours Ensure adequate hydration - the patient would have been nil by mouth for at least 6 hours prior to the procedure Bed rest for 4 hours Ensure drainage bag is placed below the level of the kidney at all times Inform the doctor if: urine output drops below 30mls over 1 hour, or urine becomes heavily blood stained (some haematuria is normal and should decrease over the first 48 hours), or the patient develops abnormal vital signs e.g. temperature above 38, hypotension, tachycardia

Answer 37

assess urine output / maintain strict fluid balance chart monitor colour in drainage bag e.g. check for haematuria monitor for signs of UTI e.g. vital signs monitor for pain, inflammation, infection at drain site wound management assessment, dressing changes using aseptic technique regular emptying of the drainage bag with appropriate hand hygiene irrigation of nephrostomy tube daily under aseptic technique as instructed by the patient's medical team and / or as per Organisational guidelines = 2-10mls of normal saline and no more than 20mls at a time nephrostomy tube must be connected to a sterile closed drainage system drainage bag should be below the level of the kidneys at all times inspect tube to ensure it is secure with no obstruction and no leakage e.g. kinked tube, sediment, leaking from connection communicate and document all treatment, progress and concerns i.e. tube not flushing, fevers, increased pain, urine output less than 30mls per hour encourage fluid intake maintain adequate analgesia education and support