AH1 Module 5 Urinary and CKD

metabolic defects that commonly cause kidney stones

-hypercalcemia -hyperoxaluria -hyperuricemia

Two main causes of CKD leading to dialysis or kidney transplantation

-hypertension -DM

kidney transplant preop care

-immunologic studies -dialysis 24 hours before surgery -blood transfusion before surgery

stress incontinence

-involuntary loss of urine during activities that increase abdominal and detrusor pressure -inability to tighten the urethra sufficiently to overcome the increased detrusor pressure -leakage of urine

acute complicated cystitis

-involves more than the bladder -symptoms of upper UTI: fever, flank pain, chills/rigors, malaise, costovertebral angle tenderness, pelvic and perineal pain in men

CKD changes

-kidney changes -metabolic changes (F/E imbalance, acid-base imbalance) -cardiac changes (HTN, hyperlipidemia, HF, pericarditis) -hematologic and immunity changes -GI changes -Cognitive and functional changes

struvite (magnesium ammonium phosphate) stones

-limit high-phosphate foods, such as diary, organ meats and whole grains

calcium phosphate stones

-limit intake of foods high in animal protein -some patients may benefit from a reduced calcium intake -decrease sodium intake

cystine stones

-limit sodium and animal protein intake -encourage oral fluid intake

donors for kidney transplant

-living donors (highest rate of graft survival) -non-heart-beating donors -cadaveric donors

kidney trauma

-may be caused by penetrating wounds, blunt injuries, urologic procedures -classified into five grades depending on severity

urinalysis bacteria

< 1000 colonies/mL -Increased indicates the need for urine culture to determine the presence of urinary tract infection.

Pubovaginal sling procedures

A sling made of synthetic or fascial material is placed under the ureterovesical junction to elevate the bladder neck.

Midurethral sling procedures

A tensionless vaginal sling is made from polypropylene mesh (or other materials) and placed near the ureterovesical junction to increase the angle, which inhibits movement of urine into the urethra with lower intravesical pressures.

Parenteral iron salts: • Iron dextran (IV) • Iron sucrose (IV)

A test dose of iron dextran is recommended before IV administration because the incidence of allergic reactions is high. Do not mix with drug with other parenteral drugs because there are many incompatibilities.

A client with end-stage kidney disease (ESKD) has this serum laboratory analysis: K+ 5.9 mEq/L Na+ 152 mEq/L Creatinine 6.2 mg/dL BUN 60 mg/dL What is the priority nursing intervention? A. Assess heart rate and rhythm. B. Implement seizure precautions. C. Assess the client's respiratory status. D. Evaluate the client's acid-base balance.

ANS: A Clients with ESKD experience significant fluid and electrolyte imbalances that are managed with medications and dialysis. Hyperkalemia can be a life-threatening event. In clients with kidney disease, the myocardial response (heart rate and rhythm) to hyperkalemia should be assessed to effectively determine appropriate treatment. High sodium can increase the client's risk for seizures, excessive fluid balance will negatively effect breathing, and clients with ESKD experience acid-base imbalances from an inability to synthesize bicarbonate.

The nurse is caring for four clients. Which client does the nurse identify that is likely experiencing stress incontinence? A. Client who laughs and cannot retain urine B. Client who feels an urge to urinate and immediately does so C. Client who has dementia and does not understand how to toilet D. Client who has not voided in 12 hours and experiences minor leakage

ANS: A Stress incontinence is the most common type of urinary incontinence. It is characterized by the inability to retain urine when laughing, coughing, sneezing, jogging, or lifting. Client B likely has urge incontinence; Client C likely has overflow incontinence; Client D likely has functional incontinence.

A 20-year-old male client reports to the college health center, reporting burning upon urination. What priority question will the nurse ask? A. "Are you sexually active?" B. "Do you have low back pain?" C. "How long have you had these symptoms?" D. "Have you had a fever in the past 24 hours?"

ANS: A The most common cause of urethritis in men is sexually transmitted infections (STIs). These include gonorrhea or nonspecific urethritis caused by Ureaplasma (a gram-negative bacterium), Chlamydia (a sexually transmitted gram-negative bacterium), or Trichomonas vaginalis (a protozoan found in both the male and female genital tracts). Other questions can be asked after assessing sexual activity and possible STI exposure.

1. A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. 4. As the client is preparing to discharge, the nurse will teach restrictions of which dietary elements? (Select all that apply.) A. Potassium B. Phosphorus C. Calcium D. Protein E. Vitamins

ANS: A, B, D Sodium is restricted because it causes retention of fluids. Potassium is restricted to prevent dangerous cardiac dysrhythmias. Vitamins must be supplemented, not restricted. There is an inverse relationship between phosphorus and calcium; when phosphorus is high, calcium is low and should not be restricted.

1. A 40-year-old client is admitted to the ED with fever, chills, and severe right flank pain. Her heart rate is 114/min and respiratory rate is 30/min. She reports recently being treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA). 2. For which diagnostic test does the nurse prepare the client? (Select all that apply.) A. CT scan B. KUB x-ray C. Thoracic MRI D. BUN and creatinine E. WBC with differential

ANS: A, B, D, E All of these diagnostic tests can be used when acute pyelonephritis is anticipated. A thoracic MRI is not indicated.

peritoneal dialysis advantages

-Flexible schedule for exchanges -Few hemodynamic changes during and following exchanges -Fewer dietary and fluid restrictions

renal system functions

-maintain body fluid, regulate electrolytes and acid-balance -eliminate waste products (uric acid, urea, ammonia, creatinine) -secrete erythropoietin to stimulate RBC production in the bone marrow -synthesize vitamin D for calcium absorption -total bladder capacity is 1L

ACE inhibitors

-"PRIL" Captopril, Enalapril, Afosiopril -Antihypertensive. -Blocks ACE in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). -Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. -Check BP before giving (hypotension) -*Orthostatic Hypotension

treatment of nephrotic syndrome

-ACE inhibitors -Heparin -dietary changes -mild diuretics -sodium restriction -hydration status

hemodialysis access

-Arteriovenous (AV) fistula -AV graft -Central venous catheter

Collection of urine specimens: Voided Urine

-Collect the first specimen voided in the morning. (Urine is more concentrated in the early morning.) -Send the specimen to the laboratory as soon as possible. (After urine is collected, cellular breakdown results in more alkaline urine.) -Refrigerate the specimen if a delay is unavoidable. (Refrigeration delays the alkalinization of urine. Bacteria are more likely to multiply in an alkaline environment.)

hemodialysis procedure

-Complex; requires a second person trained in the technique whether completed at home or at a dialysis unit/center -Special training for center personnel and in-home use

hemodialysis complications

-Disequilibrium syndrome -Muscle cramps and back pain -Headache -Itching -Hemodynamic and cardiac adverse events (hypotension, cell lysis contributing to anemia, cardiac dysrhythmias) -Infection -Increased risk for subdural and intracranial hemorrhage from anticoagulation and changes in blood pressure during dialysis -Anemia -Access site complications

Collection of urine specimens: Clean-Catch Specimen

-Explain the purpose of the procedure to the patient. (Correct technique is needed to obtain a valid specimen.) -Instruct the patient to self-clean before voiding: -Instruct the female patient to separate the labia and use the sponges and solution provided to wipe with three strokes over the urethra. The first two wiping strokes are over each side of the urethra; the third wiping stroke is centered over the urethra (from front to back). -Instruct the male patient to retract the foreskin of the penis and to similarly clean the urethra, using three wiping strokes with the sponge and solution provided (from the head of the penis downward). (Surface cleaning is necessary to remove secretions or bacteria from the urethral meatus.) -Instruct the patient to initiate voiding after cleaning. The patient then stops and resumes voiding into the container. At no time should any part of the patient's anatomy touch the lip or inner aspect of the container. Only 1 oz (30 mL) is needed; the remainder of the urine may be discarded into the commode. (A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra.) -Ensure that the patient understands the procedure. (An improperly collected specimen may result in inappropriate or incomplete treatment.) -Help the patient as needed. (The patient's understanding and the nurse's assistance ensure proper collection.)

peritoneal dialysis contraindications

-Extensive peritoneal adhesions, fibrosis, or active inflammatory GI disease (e.g., diverticulitis, inflammatory bowel conditions) -Ascites or massive central obesity -Recent abdominal surgery

Collection of urine specimens: Catheterized Specimen

-For nonindwelling (straight) catheters: (The one-time passage of a urinary catheter may be necessary to obtain an uncontaminated specimen for analysis or to measure the volume of residual urine.) Use sterile technique and follow facility procedures for urinary catheterization. (These procedures minimize bacterial entry.) -For indwelling catheters: (Urine is collected from an indwelling catheter or tubing when patients have catheters for continence or long-term urinary drainage.) • Apply a clamp to the drainage tubing, distal to the injection port for 15-30 minutes (Clamping allows urine to collect in the tubing at the location where the specimen is obtained.) • Clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic and allow to dry. Povidone-iodine solution or alcohol is acceptable. (Surface contamination is prevented by following the cleaning procedures.) • Attach a sterile 5-mL syringe into the port and aspirate the quantity of urine required. (A minimum of 5 mL is needed for culture and sensitivity (C&S) testing.) • Inject the urine sample into a sterile specimen container. (A sterile container is used for C&S specimens.) • Remove the clamp to resume drainage. • Properly dispose of the syringe.

hemodialysis contraindications

-Hemodynamic instability or severe cardiac disease -Severe vascular disease that prevents vascular access -Serious bleeding disorders

Collection of urine specimens: 24-hour Urine

-Instruct the patient thoroughly. (A 24-hr collection of urine is necessary to quantify or calculate the rate of clearance of a particular substance.) -Provide written materials to assist in instruction. -Place signs appropriately. -Inform all personnel or family caregivers of test in progress. (Instructional materials for patients, signs, etc. remind patients and staff to ensure that the total collection is completed.) -Check laboratory or procedure manual on proper technique for maintaining the collection (e.g., on ice, in a refrigerator, or with a preservative). (Proper technique prevents breakdown of elements to be measured.) -On initiation of the collection, ask the patient to void, discard the urine, and note the time. If a Foley catheter is in use, empty the tubing and drainage bag at the start time and discard the urine. -Collect all urine of the next 24 hr. -Twenty-four hours after initiation, ask the patient to empty the bladder and add that urine to the container. (Proper techniques ensure that all urine formed within the 24-hr period is collected.) -Do not remove urine from the collection container for other specimens. (Urine in the container is not considered a "fresh" specimen and may be mixed with preservative.)

overflow incontinence (reflex incontinence)

-Involuntary loss of urine associated with overdistention of the bladder when the bladder capacity has reached its maximum -Detrusor underactivity -Bladder outlet obstruction

Cinacalcet

-Monitor blood levels of calcium and phosphorus to assess drug therapy effectiveness and recognize imbalances of these important electrolytes. -Teach the patient to monitor for and report diarrhea and muscle pain (myalgia), which are indications of calcium and/or phosphorus imbalance.

• Epoetin alfa • Darbepoetin alfa

-Monitor hemoglobin values because these drugs can overproduce blood cells, which increases blood viscosity and causes hypertension. This problem increases the risk for a myocardial infarction. Dosage is individualized to produce hemoglobin levels no higher than 10-11 g/dL ( Burchum & Rosenthal, 2019 ). -Teach patients to report any of these side effects to the prescriber as soon as possible: chest pain, difficulty breathing, high blood pressure, rapid weight gain, seizures, skin rash or hives, or swelling of feet or ankles because these symptoms indicate possible serious cardiac complications.

Vitamin D: • Calcitriol • Paricalcitol • Doxercalciferol

-Monitor serum levels of calcium because this active form of vitamin D suppresses parathyroid production and can lead to hypocalcemia. -Monitor serum levels of vitamin D because this is a lipid-soluble vitamin that can be overingested and lead to toxicity. Serum calcium levels should stay below 10 mg/dL

hemodialysis advantages

-More efficient clearance of wastes -Short time needed for treatment

urge incontinence

-Overactive bladder (OAB) -Involuntary loss of urine associated with a strong desire to urinate -Inability to suppress the signal from the bladder muscle to the brain that it is time to urinate

peritoneal dialysis complications

-Protein loss -Peritonitis -Respiratory distress -Inflammatory bowel disease -Bowel perforation -Infection -Weight gain; discomfort from "carrying" 1-2 L in abdomen during dwell time; potential for back pain or development of hernia

Magnetic resonance imaging (MRI)

-Similar to CT -Useful for staging of cancers

peritoneal dialysis procedure

-Simple, easier to complete at home compared with at-home hemodialysis -Less complex training; typically managed by patient; can be managed by one person

Phosphate binders form an insoluble calcium-phosphate complex to inhibit GI absorption to prevent hyperphosphatemia and renal osteodystrophy from hypocalcemia: • Calcium acetate • Calcium carbonate Noncalcium phosphate binders reduce blood phosphate levels without disturbing calcium levels: • Lanthanum carbonate • Sevelamer

-Teach patients to take drugs with meals to increase the effectiveness in slowing or preventing the absorption of dietary phosphorus. -Teach patients not to take these drugs within 2 hours of other scheduled drugs to prevent the inhibited absorption of other drugs, especially cardiac drugs and antibiotics. -Monitor both serum phosphorus and calcium levels because these drugs lower phosphorus and can cause hypercalcemia. -Monitor for constipation because these can cause significant constipation, leading to fecal impaction or ileus. -Teach patients to report muscle weakness, slow or irregular pulse, or confusion to the prescriber because these are symptoms of hypophosphatemia and indicate that dosage adjustment is required.

Oral iron salts • Ferrous sulfate • Ferrous fumarate • Ferrous gluconate

-Teach patients to take stool softeners daily while taking iron supplements, which can cause constipation. -Remind patients that iron supplements change the color of the stool because knowing the expected side effects decreases anxiety when they appear.

Multivitamins and vitamin B supplements • Folic acid/folate • Cyanocobalamin (B12)

-Teach patients to take the drugs after dialysis to prevent the supplement from being removed from the blood during dialysis. -Teach patients to take iron supplements (ferrous sulfate) with meals to reduce nausea and abdominal discomfort.

Metabolic imaging with positron emission tomography (PET)

-To evaluate cysts, tumors, and other lesions, eliminating the need for biopsy in some patients

(Nuclear) renal scan

-To evaluate renal perfusion -To estimate glomerular filtration rate -To provide functional information without exposing the patient to iodinated contrast medium

Cystoscopy

-To identify abnormalities of the bladder wall and urethral and ureteral occlusions -To treat small obstructions or lesions via fulguration, lithotripsy, or removal with a stone basket

Ultrasonography (US) Can be used with contrast media

-To identify the urine volume in the bladder, size of the kidneys or obstruction (e.g., tumors, stones) in the kidneys or lower urinary tract -Assess blood flow to and from the kidney

Computed tomography (CT) with contrast, CT arteriography or angiography

-To measure kidney size -To evaluate contour to assess for injury, masses, or obstruction in kidneys or the urinary tract -To assess renal blood flow

Cystography and cystourethrography With or without retrograde studies With or without contrast medium

-To outline bladder's contour when full and examine structure during voiding -To examine the structure of the urethra -To detect backward urine flow

Radiography of kidneys, ureters, and bladder (KUB) (plain film of abdomen)

-To screen for the presence of two kidneys -To measure kidney size -To detect gross obstruction in kidneys or urinary tract

acute uncomplicated cystitis

-acute UTI (bladder involvement only) -no signs/symptoms of upper UTI -no anatomic or functional abnormality of the urinary tract or condition that increases the risk for infection or possibility of treatment failing to resolve the infection

renal cell carcinoma

-adenocarcinoma of kidney -most common type of kidney cancer -accompanied by paraneoplastic syndromes -usually metastasizes to adrenal gland, liver, lungs, long bones, or other kidney

candidate selection criteria for kidney transplant

-advanced kidney disease -reasonable life expectancy -medically and surgically fit for procedure -in US waiting list when GFR <20 mL/min

acute kidney injury interventions

-avoid hypotension -maintain normal fluid balance -reduce exposure to nephrotoxic agents and drugs -frequently monitor lab values -closely watch I/O -drug therapy -nutrition -kidney replacement therapy

kidney transplantation

-candidate selection criteria -donors -pre/postop care -immunosuppression therapy

risk for urinary incontinence increases with

-chronic conditions -vaginal deliveries -pelvis prolapse -prostate problems -diabetes -heart failure -obesity

kidney and urinary changes associated with aging

-cortical tissue loss -smaller nephrons -blood flow to kidneys declines -decreased GFR -nocturia -decreased bladder capacity -weakened urinary sphincters and shortened urethra in women -tendency to retain urine

factors contributing to urinary incontinence

-drugs -disease -depression -inadequate resources

hydronephrosis and hydroureter assessment

-focus history on kidney or urologic disorders -childhood UTIs may be relevant -may experience flank or abdominal pain, chills, fever, malaise -inspect flanks, palpate abdomen gently, use bladder scanner -diagnostic testing includes urinalysis, BUN and creatinine; US or CT

polycystic kidney disease (PKD)

-genetic disorder -fluid filled cysts develop in nephrons -patients with PKD often experience hypertension, abdominal fullness and pain, cyst bleeding, hematuria, kidney stone formation, infections, systemic disease

nephrotic syndrome

-glomerular permeability increases -allows larger molecules to pass through the membrane into urine and be excreted -massive loss of protein into urine, edema formation and decreased plasma albumin levels -most common cause is altered immunity with inflammation

signs and symptoms of benign prostatic hypertrophy

-hematuria -nocturia -decrease in urine force -UTIs

kidney replacement therapies

-hemodialysis -peritoneal dialysis

post op care benign prostatic hypertrophy

-monitor for shock and hemorrhage -avoid heavy lifting -avoid prolonged sitting -constipation -straining -monitor for continuous bladder irrigation -fluid 3L /day -assess for TURP syndrome (hyponatremia, confusion, bradycardia, hypo/hypertension, nausea, vomiting, visual changes); keep catheter taped tightly to the clients leg; teach Kegel exercises

symptoms of urethritis

-mucopurulent or purulent discharge -dysuria -discomfort

The patient with urinary incontience

-note the presence of risk factors -detail the symptoms -obtain a 24-hour intake and output record or a voiding diary -assess the patients mobility, self-care ability, cognitive ability and communication patterns -assess the environment for barriers to toileting (privacy, restrictive clothing, access to toilet)

factors contributing to UTIs

-obstruction -Stones (calculi) -Vesicoureteral reflux -diabetes mellitus -characteristics of urine -gender -age sexual activity -recent use of antibiotics -virulence factors

chronic rejection

-onset occurs gradually during a period of months to years -gradual increase in BUN and serum creatinine levels -fluid retention -changes in serum electrolyte levels -fatigue -conservative management until dialysis required

acute rejection

-onset within 1 wk to any time after surgery; occurs over days to weeks -oliguria or anuria -temp over 100F -increased BP -enlarged, tender kidney -lethargy -elevated serum creatinine, BUN, potassium levels -fluid retention -increased doses of immunosuppressive drugs

hyperacute rejection

-onset within 48 hours after surgery -increased temp -increased BP -pain at transplant site -immediate removal of the transplanted kidney

diseases and conditions that contribute to acute kidney injury

-perfusion reduction -kidney damage -urine flow obstruction

kidney transplant operative procedure

-procedure varies depending on status of donor -failed kidneys are left in place (unless infected, enlarged or causing pain) -new kidney placed in right or left anterior iliac fossa

renovascular disease

-processes affecting renal arteries may severely narrow lumen, greatly reduce blood flow to kidneys -often occurs in people over 50 with a sudden onset of HTN

risk factors for acute kidney injury

-shock -cardiac surgery -hypotension -prolonged mechanical ventilation -sepsis

Key features of renovascular disease

-significant, difficult to control HTN -poorly controlled DM -sustained hyperglycemia -elevated serum creatinine -decreased GFR -diagnosis made by MRA, renal US, radionuclide imaging or renal arteriography

chronic glomerulonephritis interventions

-slow progression of disease; prevent complications -dietary changes -fluid intake -drug therapy -eventually, dialysis or transplantation

urinary incontinence temporary or permanent causes

-surgery -spinal cord injury S2 to S4 -brain and nervous system disorders -disease treatment -drugs -factors associated with aging

side effects of intravenous urography

-throat irritation -flushing of face -warmth -salty/metallic taste during the test

kidney transplant postoperative care

-urologic management -assess hourly urine output for 48 hours -CBI (occasionally prescribed) -monitor I/O -Complications (rejection, thrombosis, renal artery stenosis) -immunosuppressive drug therapy

diabetic nephropathy

-vascular complication of DM -leading cause of CKD worldwide -severity is related to degree of hyperglycemia the patient generally experiences -management is the same as for CKD

urinalysis RBCs

0-2 -Increased is normal with catheterization or menses but may reflect tumor, stones, trauma, glomerular disorders, cystitis, or bleeding disorders.

urinalysis WBCs

0-4 -Increased may indicate an infection or inflammation in the kidney and urinary tract, kidney transplant rejection, or exercise.

urinalysis protein

0-8 mg/dL -Increased amounts may indicate stress, infection, recent strenuous exercise, or glomerular disorders.

serum creatinine

0.6-1.2 mg/dL -increased level indicates kidney impairment -decreased level may be caused by decrease muscle mass

specific gravity

1.010-1.030 -Increased in decreased kidney perfusion, inappropriate ADH secretion, or heart failure. -Decreased in chronic kidney disease, diabetes insipidus, malignant hypertension, diuretic administration, and lithium toxicity.

BUN

10-20 mg/dL -An increased level may indicate liver or kidney disease, dehydration or decreased kidney perfusion, a high-protein diet, infection, stress, steroid use, Gl bleeding, or other situations in which blood is in body tissues. -A decreased level may indicate malnutrition, fluid volume excess, or severe hepatic damage.

arterial blood bicarbonate

21-28 mEq/L

serum carbon dioxide w BICARB (CO2)

23-30 low/decreased in renal failure

blood osmolality

285-295 mOsm/kg

arterial blood PaCO2

35-45 mm Hg

urinalysis pH

4.6-8 -Changes are caused by diet, drugs, infection, age of specimen, acid-base imbalance, and kidney disease.

BUN/creatinine Ratio

6-25 15.5 -An increased ratio may indicate fluid volume deficit, obstructive uropathy, catabolic state, or a high-protein diet. -A decreased ratio may indicate fluid volume excess.

arterial blood pH

7.35-7.45

Artificial sphincters

A mechanical device to open and close the urethra is placed around the anatomic urethra.

The nurse is caring for four clients. Which client does the nurse identify at highest risk for acute pyelonephritis? A. 18-year-old male with spinal cord injury B. 24-year-old female with urinary reflux C. 31-year-old male with HIV infection D. 40-year-old female with urinary tract stones

ANS: B Acute pyelonephritis is most commonly seen in 20 to 30 year old female. Reflux is a key contributor. The conditions of other clients is characteristic of chronic pyelonephritis.

The nurse is caring for a client with polycystic kidney disease. Which assessment finding requires immediate nursing intervention? A. Temperature of 99° F B. Blood pressure of 170/90 C. Heart rate of 100 beats/min D. Urine output of 40 cc/hr

ANS: B Clients with polycystic kidney disease often have high blood pressure. The cause of hypertension is related to kidney ischemia from the enlarging cysts. As the vessels are compressed and blood flow to the kidneys decreases, the renin-angiotensin system is activated, raising blood pressure. Control of hypertension is a top priority because proper treatment can disrupt the process that leads to further kidney damage. Other findings can be assessed after addressing hypertension.

1. A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. 3. Following dialysis, what assessment finding does the nurse anticipate? A. Weight increased after dialysis. B. Temperature higher following dialysis. C. Clotting studies reduced post-dialysis. D. Blood pressure higher than pre-dialysis.

ANS: B The client's temperature is elevated after dialysis because the dialysis machine warms the blood slightly. Weight and blood pressure should be decreased because excess fluid is removed during dialysis. Heparin is required during hemodialysis and increases clotting time.

1. A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. Which drug should be held until after the dialysis treatment? A. Calcium B. Atenolol C. Glyburide D. Multivitamin

ANS: B Vasoactive drugs such as beta blockers like atenolol can cause hypotension during dialysis and are usually held until after treatment.

Which assessment finding does the nurse anticipate for a client with chronic glomerulonephritis? (Select all that apply.) A. Increased urinary output B. Specific gravity of 1.010 C. Red blood cells in the urine D. Serum creatinine of 5 mg/dL E. Sodium level of 130 mEq/L

ANS: B, C Options B and C are expected findings in a client with chronic glomerulonephritis. This client would also have decreased urinary output, serum creatinine of < 6 mg/dL, and a sodium level of > 135 mEq/L. The other findings are not anticipated.

A client with kidney failure whose pulse oximeter reading is 96% reports dyspnea. The nurse assesses that the client is visibly distressed, with a respiration rate of 32 breaths/minute. What is the appropriate nursing intervention? A. Notify the respiratory therapist. B. Contact the health care provider. C. Administer oxygen by nasal cannula. D. Elevate the head of bed to 90 degrees.

ANS: C Clients with kidney failure are anemic because they cannot produce the hormone erythropoietin. A high oxygen saturation in an anemic client who is showing signs of respiratory distress may still be hypoxemic. Clients who have decreased hemoglobin could have a high percentage of the hemoglobin saturated with oxygen, but because they have a decreased hemoglobin level, not enough oxygen is provided. Administering oxygen is necessary.

Which assessment finding in a client with AKI requires immediate nursing intervention? A. Heart rate of 120 beats/min B. Blood pressure of 156/88 C. Urine specific gravity of 1.001 mm Hg D. Intake of 2000 mL and output of 1500 mL in the past 24 hours

ANS: C Decreased urine specific gravity indicates a loss of urine-concentrating ability and is the earliest sign of renal tubular damage and early kidney failure. Normal urine specific gravity ranges from 1.002 to 1.028. Assessing the client's perfusion status is also very important in the prevention and/or treatment of kidney disease.

1. A 71-year-old woman with chronic kidney disease and a history of type 2 diabetes had surgery two weeks ago to place a vascular graft access for hemodialysis. She is to have hemodialysis this morning. 2. The client's daughter asks why her mother must be weighted before and after the dialysis treatment. What is the appropriate nursing response? A. "It is part of the protocol for dialysis." B. "It ensures that she is getting adequate nutrition." C. "It estimates the amount of fluid and sodium your mother is retaining and how much is taken off during dialysis." D. "It is essential for calculating the fluid restriction your mother will receive on non-dialysis days."

ANS: C The best way to estimate fluid and sodium retention and removal is by weighing the client.

The nurse is caring for a client who will soon receive a kidney transplant. When the client says, "what will I do if this transplant doesn't work?", what is the appropriate nursing response? A. "Try to focus on getting through the surgery first." B. "Kidney transplants are almost always successful." C. "It sounds like you are concerned about the outcome of the procedure." D. "If this transplant doesn't work, I'm sure there will be another donor soon."

ANS: C The nurse should allow the client to express his or her feelings; the client's question demonstrates concern—possibly anxiety or fear—and the nurse allows further exploration of those feelings by verbalizing the implied. Response B gives false reassurance; response D dismisses the client's feelings; response A does not address the client's feelings.

The nurse has placed an indwelling urinary catheter via sterile technique into a client. The nurse recognizes that it is how long before bacterial colonization begins? A. 12 hours B. 24 hours C. 48 hours D. 72 hours

ANS: C Within 48 hours of catheter insertion, bacterial colonization along the urethra and the catheter itself begins. Risks for infection associated with a catheter increases 3%-10% per day the catheter is in place (Ferguson, 2018).

A client with a history of kidney disease is admitted with acute shoulder pain. Which order will the nurse discuss with the prescribing health care provider? A. Digoxin 0.125 mg by mouth daily B. Metoprolol 50 mg by mouth twice daily C. Pan cultures for a temperature >38.5º C D. Ibuprofen 800 mg by mouth every 4 hours

ANS: D High-dose or long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) can seriously reduce kidney function, so the nurse will discuss this with the prescribing health care provider.

1. A 40-year-old client is admitted to the ED with fever, chills, and severe right flank pain. Her heart rate is 114/min and respiratory rate is 30/min. She reports recently being treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA) Two days later during the nursing assessment, the client expresses embarrassment. She reports not taking the full treatment of antibiotics prescribed for the UTI she had recently. What is the appropriate nursing response? A. "The next time you will know to do better." B. "Why didn't you take all of your medication?" C. "Superbugs can develop when antibiotics aren't finished." D. "Can you tell me more about why you didn't take all of your antibiotics?"

ANS: D Response D is nonjudgmental and encourages the client to share more. This response may also offer an opportunity for client teaching. Responses A and C are true, but are nontherapeutic and do not help relieve the client's embarrassment. Response B is judgmental.

Which client does the nurse identify as most likely to experience renal compromise assessed by decreased urine production? A. 12-year history of diabetes mellitus . White blood cell count of 13,000/mm3 C. Recent history of myocardial infarction D. Blood pressure of 92/48 mm Hg for 12 hours

ANS: D The ability of the kidneys to self-regulate renal blood pressure and renal blood flow keeps the glomerular filtration rate (GFR) constant. A blood pressure of 92/48 mm Hg is a mean arterial pressure of 62 mm Hg. The kidney has a difficult time regulating GFR with a mean arterial blood pressure less than 65 mm Hg.

1. A 40-year-old client is admitted to the ED with fever, chills, and severe right flank pain. Her heart rate is 114/min and respiratory rate is 30/min. She reports recently being treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA). 1. What condition does the nurse anticipate? 2. What laboratory tests does the nurse anticipate will be ordered?

ANS:1. Acute pyelonephritis.2. Urinalysis—positive leukocyte esterase and nitrite dipstick test, presence of white blood cells (WBCs) and bacteria; urine culture and sensitivity (C&S); blood cultures; C-reactive protein; erythrocyte sedimentation rate.

subcutaneous catheter

An internal device with two access ports and a cuff or dual-lumen catheter inserted into a large central vein -subclavian vein -internal jugular -femoral vein -Dedicated use; do not access for blood sampling or drug administration

AKI is more common as people age. People aged 80 to 89 years of age are 55% more likely to develop AKI than people under age 50.

As the kidneys age, structural and functional changes occur including fewer nephrons and sclerosis of glomeruli and the renal arteries. These changes lead to an increased risk for AKI. Older adults also have more comorbid conditions such as diabetes, hypertension, and chronic kidney disease.

renin (an enzyme) is released from the nephron when

BP or fluid concentration is low

CKD Clinics Improving Patient Outcomes

CKD is a complex disease that affects physical, mental, and social aspects of health. This requires an understanding of available resources in order to improve patient outcomes. CKD clinics use an interprofessional approach, treating all aspects of the patient's health. Hospitals that develop and maintain clinics for patients with chronic diseases such as heart failure and CKD have fewer hospital readmissions and better patient outcomes. CKD clinics are successful because they foster care coordination and promote convenience for the patient. The following services are recommended at a CKD clinic: • Scheduling of tests (such as ultrasound and CT scans) • Scheduling of specialist appointments as necessary • Providing reminders for appointments and tests • Following up with test results • Providing a patient liaison for pharmacy and laboratory tests • Consulting with interprofessional team members such as registered dietitian nutritionists (RDNs) • Educating regarding disease processes, transplants, and therapies • Referring as necessary for dialysis catheter insertion

Retropubic suspension (Marshall-Marchetti-Krantz or Burch colposuspension)

Elevates the urethral position and provides longer-lasting results

Needle bladder neck suspension (Pereyra or Stamey procedure)

Elevates the urethral position and provides longer-lasting results without a long operative time

anterior vaginal repair (colporrhapy)

Elevates the urethral position and repairs any cystocele

Monitor the patient to recognize indications of peritonitis (e.g., cloudy dialysate outflow (effluent), fever, abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting). Cloudy or opaque effluent is the earliest indication of peritonitis

Examine all effluent for color and clarity to detect peritonitis early. When peritonitis is suspected, respond by sending a specimen of the dialysate outflow for culture and sensitivity study, Gram stain, and cell count to identify the infecting organism.

hyperuricemia

Excess of uric acid in the blood (gout)

hemoglobin

Female: 12-16 g/dL (7.4-9.9 mmol/L) Male: 14-18 g/dL (8.7-11.2 mmol/L) Older adults: Slightly decreased

5 Stages of CKD are based on

GFR

Stage 4 CKD

GFR 15-29 -Severely reduced kidney function -a noticeable jaundice can occur, particularly around the eyes

Stage 3 CKD

GFR 30-59 moderately reduced kidney function

Stage 2 CKD

GFR 60-89 slightly reduced kidney function

Stage 5 CKD

GFR <15 End-stage renal disease (ESRD)

Stage 1 CKD

GFR >90 At risk; normal kidney function, but urine findings indicate kidney disease

Monitor the patient closely during dialysis to recognize hypotension, which is common.

Heat transfer from warm solutions can result in vasodilation and a drop in blood pressure. When this occurs, reduce the temperature of the dialysate to 35°C (95°F). Fluid shifts from the plasma volume related to differences in electrolyte concentrations between HD solutions and blood also reduce blood pressure. Respond to modest declines in blood pressure by adjusting the rate of dialyzer blood flow and placing the patient in a legs-up (Trendelenburg) position. Respond to sustained or symptomatic hypotension by giving a fluid bolus of 100 to 250 mL of normal saline, albumin, or mannitol (if prescribed). A second bolus may be needed. If hypotension persists, new-onset myocardial injury or pericardial disease may be a contributing factor; respond by applying oxygen, reducing the blood flow, and notifying the primary health care provider urgently. Discontinue HD when hypotension continues despite two bolus infusions.

Because repeated compression can result in the loss of the vascular access,

avoid taking the blood pressure or performing venipunctures in the arm with the vascular access. Do not use an AV fistula or graft for general delivery of IV fluids or drugs.

urosepsis

bacteremia; spread of the infection from the urinary tract to the bloodstream

Periurethral injection of collagen or Siloxane

Implantation of small amounts of an inert substance through several small injections provides support around the bladder neck.

loop diuretics

Increase urine output to manage volume overload when urinary elimination is still present. • Furosemide • Bumetanide • Dose varies with severity of kidney damage; not effective in ESKD -Monitor intake and output to assess therapy effectiveness. Generally the expected outcome is for output to be greater than intake by 500-1000/mL/24 hr. -Monitor electrolytes because these drugs result in loss of potassium; this can be a desired effect in patients with hyperkalemia.

peritoneal dialysis access

Intra-abdominal catheter

bradykinins

Juxtaglomerular cells of the arterioles; Increase blood flow (vasodilation) and vascular permeability

Prostaglandins

Kidney tissues; Regulate intrarenal blood flow by vasodilation or vasoconstriction

functional incontinence

Leakage of urine caused by factors other than disease of the lower urinary tract

systemic complications from acute kidney injury

Metabolic • Metabolic acidosis • Hyperlipidemia • Hyperkalemia • Hyponatremia • Hypocalcemia • Hypophosphatemia Cardiopulmonary • Peripheral and pulmonary edema • Heart failure • Pulmonary embolism • Pericarditis • Pericardial effusion • Hypertension • Myocardial infarction Neurologic • Neuromuscular irritability or weakness • Asterixis • Seizures • Mental status changes Immune/Infectious • Pneumonia • Sepsis Gastrointestinal • Nausea • Vomiting • Decreased peristalsis • Enteral nutrition intolerance • Malnutrition • Ulcer formation • Bleeding Hematologic • Bleeding • Thrombosis • Anemia Renal • Chronic kidney disease (CKD) • End-stage kidney disease (ESKD) Other • Hiccups • Elevated parathyroid hormone • Low thyroid hormone level

diffusion

Movement of molecules from an area of higher concentration to an area of lower concentration.

signs and symptoms of severe, chronic and end-stage kidney disease

Neurologic Symptoms • Lethargy and daytime drowsiness • Inability to concentrate or decreased attention span • Seizures • Coma • Slurred speech • Asterixis (jerky movements or "flapping" of the hands) • Tremors, twitching, or jerkymovements • Myoclonus • Ataxia (alteration in gait) • Paresthesias from peripheralneuropathy Cardiovascular Symptoms • Cardiomyopathy • Hypertension • Peripheral edema • Heart failure • Uremic pericarditis • Pericardial effusion • Pericardial friction rub • Cardiac tamponade • Cardiorenal syndrome Respiratory Symptoms • Uremic halitosis • Tachypnea • Deep sighing, yawning • Kussmaul respirations • Uremic pneumonitis • Shortness of breath • Pulmonary edema • Pleural effusion • Depressed cough reflex • Crackles Hematologic Symptoms • Anemia • Abnormal bleeding and bruising • Reduced white blood cell count • Increased risk for infection Gastrointestinal Symptoms • Anorexia • Nausea • Vomiting • Metallic taste in the mouth • Changes in taste acuity andsensation • Uremic colitis (diarrhea) • Constipation • Uremic gastritis (possible GI bleeding) • Uremic fetor (breath odor) • Stomatitis Urinary Symptoms • Polyuria, nocturia (early) • Oliguria, anuria (later) • Proteinuria • Hematuria • Diluted, straw-colored urine appearance (early) • Concentrated and cloudy urine appearance (later) Integumentary Symptoms • Decreased skin turgor • Yellow-gray pallor • Dry skin • Pruritus • Ecchymosis • Purpura • Soft-tissue calcifications • Uremic frost (late, premorbid) Musculoskeletal Symptoms • Muscle weakness and cramping • Bone pain • Fractures • Renal osteodystrophy Reproductive Symptoms • Decreased fertility • Infrequent or absent menses • Decreased libido • Impotence • Sexual dysfunction Metabolic Symptoms • Hyperparathyroidism • Hyperlipidemia • Alterations in vitamin D, calcium, and phosphorus adsorption and metabolism • Metabolic acidosis • Hyperkalemia Psychosocial Symptoms • Depression • Fatigue • Sleep disturbances • Sexual dysfunction • Cognitive impairment • Unemployment

peritubular capillaries (PTCs) and vasa recta (VR)

PTCs: surround tubular components of cortical nephrons; VR: surround tubular components of juxtamedullary nephrons; tubular reabsorption and tubular secretion allow movement of water and solutes to or from the tubules, interstitium and blood

ureterostomies

divert urine directly to the skin surface through a ureteral skin opening (stoma)

renin

Renin-producing granular cells; Raises blood pressure as result of angiotensin (local vasoconstriction) and aldosterone (volume expansion) secretion

In any acute care setting, preventing volume depletion and providing intervention early when volume depletion occurs are nursing priorities. Reduced perfusion from volume depletion is a common cause of AKI. Assess continually to recognize the signs and symptoms of volume depletion (low urine output, decreased systolic blood pressure, decreased pulse pressure, orthostatic hypotension, thirst, rising blood osmolarity).

Respond by intervening early with oral fluids or, in the patient who is unable to take or tolerate oral fluid, requesting an increase in IV fluid rate from the primary health care provider to prevent permanent kidney damage.

ileal reservoirs

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-catherization

Sulfamethoxazole/trimethoprim should be stopped at the first appearance of a skin rash. A rash may indicate

Sulfamethoxazole/trimethoprim should be stopped at the first appearance of a skin rash. A rash may indicate

African Americans have more rapid age-related decreases in GFR than do white adults. Kidney excretion of sodium is less effective in hypertensive African Americans who have high sodium intake, and the kidneys have about 20% less blood flow as a result of anatomic changes in small blood vessels and intrarenal responses to renin.

Thus African-American patients are at greater risk for kidney failure than are white patients. Yearly health examinations should include urinalysis, checking for the presence of microalbuminuria, and evaluating serum creatinine.

Erythropoietin-Stimulating Agents (ESAs)

Used to prevent or correct anemia caused by kidney disease through the stimulation of the bone marrow to increase red blood cell production and maturation.

Parathyroid Hormone Modulator

Used to reduce parathyroid gland production of parathyroid hormone by decreasing the gland's sensitivity to calcium. This action helps maintain blood calcium and phosphorus levels closer to normal and can reduce renal osteodystrophy in patients with chronic kidney disease.

Vitamins and Minerals

Used to replace those lost through dialysis or poorly absorbed as a result of dietary restrictions and to lower vitamin or mineral excesses that could lead to more problems.

cystitis

a bladder inflammation, most often with infection -irritants can cause without infection

interstitial cystitis

a chronic inflammation within the walls of the bladder

abscess

a localized collection of pus caused by an inflammatory response to bacteria in tissues and organs

urgency

a sense of a nearly uncontrollable need to urinate

dialysis catheter

a specially designed catheter with separate lumens for blood outflow and inflow -subclavian vein -internal jugular -femoral vein -used immediately after insertion and x-ray confirmation of placement

clean catch urine specimen

a urine specimen obtained by cleaning the genitalia and then capturing a midstream urine sample for laboratory analysis

hyperpnea

abnormal increase in the depth of respiratory movements

trabeculation

abnormal thickening of the bladder wall caused by urinary retention and obstruction

anuria

absence of urine output

A serum creatinine of 1.5 mg/dL (110 mcmol/L) or greater places a patient at risk for

acute kidney injury (AKI) from iodinated contrast media and some drugs

Ensure that the patient who is prescribed metformin does not receive the drug after a procedure requiring IV contrast material until

adequate kidney function has been determined.

angiotensin II (potent vasoconstrictor) stimulates the secretion of

aldosterone

hypercalcemia

an abnormally high level of calcium in the blood

bruit

an audible swishing sound produced when the volume of blood or the diameter of the blood vessel changes

Glomerulonephritis can lead to chronic kidney disease, making it essential to prevent and treat in the older adult who is at greater risk for CKD. In the older adult, symptoms of glomerulonephritis can easily be confused with

an exacerbation of heart failure. Older adults with glomerulonephritis have a higher risk of mortality than younger patients with the same diagnosis, adding to the importance of early recognition and prompt intervention

AV fistula

an internal anastomosis of an artery to a vein -forearm -upper arm -2 to 3 months or longer for initial use

angiotensin-converting enzyme (ACE, from the lungs) converts angiotensin I to

angiotensin II

Cefdinir, cefaclor, or cefpodoxime

antibiotic to treat UTI -Ask about drug allergies to penicillin or cephalosporins before beginning drug therapy because these drugs are structurally similar to penicillin and anyone with allergies to penicillin is likely to be allergic to the cephalosporins. -Instruct patients to call the prescriber if severe or watery diarrhea develops to recognize the complication of pseudomembranous colitis, which may require discontinuing the drug. -Caution patients to complete the drug regimen even if the symptoms improve or disappear sooner to prevent bacterial resistance and infection recurrence. -Instruct patients to follow the directions on the label if the medication needs to be reconstituted. Add water as directed and shake well to ensure that all particles are mixed thoroughly and the correct dose is taken. -Avoid taking this drug when also taking metoclopramide or any other drug that increases GI motility to prevent interference with drug absorption. -Teach patients to shake the bottle well before measuring the drug to thoroughly mix the suspension. -Suggest that patients obtain a calibrated spoon for liquid drugs and not to use household spoons to ensure accurate dosing. -Teach patients to drink a full glass of water with each dose and to have an overall fluid intake of at least 3 L daily to avoid having the drug precipitate in the kidneys and cause kidney damage. -Caution patients to complete the drug regimen even if the symptoms improve or disappear sooner to prevent bacterial resistance and infection recurrence.

Amoxicillin Amoxicillin/clavulanate

antibiotic to treat UTI -Ask patients about drug allergies to penicillin before beginning drug therapy because allergies to this drug category are common. -Teach patients to take the drug with food to reduce the risk for GI upset. -Instruct patients to call the primary health care provider if severe or watery diarrhea develops to recognize the complication of pseudomembranous colitis, which may require discontinuing the drug. -Suggest that women who take oral contraceptives use an additional method of birth control while taking this drug because these drugs may reduce the effectiveness of estrogen-containing contraceptives. -Caution patients to complete the drug regimen even if the symptoms improve or disappear sooner to prevent bacterial resistance and infection recurrence.

Trimethoprim/Sulfamethoxazole (Bactrim)

antibiotic to treat UTI -Ask patients about drug allergies, especially to sulfa drugs, before beginning drug therapy because allergies to sulfa drugs are common and require changing drug therapy. -Teach patients to drink a full glass of water with each dose and to have an overall fluid intake of 3 L daily because these drugs can form crystals that precipitate in the kidney tubules. Fluids can prevent this complication. -Teach patients to keep out of the sun or to wear protective clothing outdoors and use a sunscreen because these drugs increase sun sensitivity and can lead to severe sunburn. -Caution patients to complete the drug regimen even if the symptoms improve or disappear sooner to prevent bacterial resistance and infection recurrence.

Phenazopyridine

antibiotic to treat UTI -Remind patients that this drug will not treat an infection, only the symptoms because these drugs have no antibacterial activity. -Teach patients to take the drug with or immediately after a meal to reduce the risk for GI upset. -Warn patients that urine will turn red or orange to reduce anxiety about this change.

Ciprofloxacin, levofloxacin ofloxacin

antibiotic to treat UTI -Teach patients taking the extended-release drugs to swallow them whole and not to crush or chew the tablets because this action ruins the extended effect. -Warn patients not to take the drug within 2 hours of taking an antacid to prevent interference with drug absorption. -Teach patients how to take their pulse, to monitor it twice daily while on this drug, and to notify the primary health care provider if new-onset irregular heartbeats occur to identify serious drug-induced dysrhythmias. -Teach patients to keep out of the sun or to wear protective clothing outdoors and use a sunscreen to avoid serious sunburns from increased sun sensitivity. -Caution patients to complete the drug regimen even if the symptoms improve or disappear sooner to reduce bacterial resistance and infection recurrence.

Hyoscyamine

antibiotic to treat UTI -Teach patients to notify the primary health care provider if blurred vision or other eye problems, confusion, dizziness or fainting spells, fast heartbeat, fever, or difficulty passing urine occurs because these symptoms indicate drug toxicity. -Teach patients to wear dark glasses in sunlight or other bright-light areas because these drugs dilate the pupil and increase eye sensitivity to light.

urodynamic testing

assesses how well the bladder and urethra are storing and releasing urine

pyelonephritis

bacterial infection that starts in the bladder and moves upward to infect the kidneys -abscesses can develop on kidneys -commonly caused by E. Coli or Enterococcus faecalis

neobladder

bladder constructed from portions of intestine connected to the urethra, allowing "natural" voiding

melena

blood in the stool with the appearance of black, tarry stool

renal osteodystrophy

bone metabolism and structural damage caused by CKD; induced low calcium levels and high phosphorus levels

Kussmaul respirations

breathing pattern with respirations that are fast and deep; often associated with metabolic acidosis

glomerulus

capillary loops with thin, semipermeable membrane; site of glomerular filtration

natriuretic hormones

cardiac atria, cardiac ventricles, brain; cause tubular secretion of sodium

urinalysis turbidity

clear -Cloudy urine indicates infection, sediment, or high levels of urine protein.

collecting ducts

collect forme3d urine from several tubules and deliver it into the renal pelvis; receptor sites for antidiuretic hormone regulation of water balance

conduits

collect urine in a portion of the intestine, which is then opened onto the skin surface as a stoma

uremic syndrome

increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions

juxtaglomerular complex

consists of specialized cells that secrete renin when glomerular blood pressure decreases

Loop of Henle

continues from PTC; Juxtamedullary nephrons dip deep into the medulla; permeable to water, urea, and sodium chloride; regulation of water balance

descending limb (DL)

continues from the loop of Henle; permeable to water, urea, and sodium chloride; regulation of water balance

uric acid (urate) stones

decrease intake of purine sources such as organ meats, poultry, fish, gravies, red wines and sardines

nephrosclerosis

degenerative disorder resulting from changes in kidney blood vessels -nephron blood vessels thicken -narrowed lumens and decreased kidney blood flow -occurs with HTN, atherosclerosis, diabetes mellitus -may be reversible or progress to ESRD

afferent arteriole

delivers arterial blood from the branches of the renal artery into the glomerulus; autoregulation of renal blood flow via vasoconstriction or vasodilation; renin-producing granular cells

efferent arteriole

delivers arterial blood from the glomerulus into the peritubular capillaries or the vasa recta; autoregulation of renal blood flow via vasoconstriction or vasodilation; renin-producing granular cells

bladder scan

device used by the nurse at bedside to measure the amount of urine in the bladder

chronic glomerulonephritis

diminished function of the kidney due to damage to the filtration membrane -develops over years to decades -symptoms may include mild proteinuria, hematuria, hypertension, fatigue, occasional edema -exact cause not known

cardiorenal syndrome

disorders of the kidney or heart that cause dysfunction in the other organ

hematocrit

emale: 37%-47% (0.37-0.47 volume fraction) Male: 42%-52% (0.42-0.52 volume fraction) Older adults: May be slightly decreased

ascending limb (AL)

emerges from DL as it turns and is redirected up toward the renal cortex; potassium and magnesium reabsorption in the thick segment; thin segment is impermeable to water

transurethral resection of prostate (TURP)

enlarged portion of prostate is removed though endoscopic instrument

hydronephrosis

enlargement of the kidney caused by blockage of urine lower in the tract and filling of the kidney with urine

hydroureter

enlargement of the ureter

distal convoluted tubule (DCT)

evolves from AL and twists, so the macula densa cells lie adjacent to the juxtaglomerular cells of afferent arteriole; site of additional water and electrolyte reabsorption, including bicarbonate, potassium and hydrogen secretion

proximal convoluted tubule (PCT)

evolves from and is continuous with Bowman capsule; specialized cellular lining facilitates tubular reabsorption; site for reabsorption of sodium, chloride, water, glucose, amino acids, potassium, calcium, bicarbonate, phosphate and urea

hyperoxaluria

excessive urinary excretion of oxalate

nephrolithiasis

formation of stones in the kidney

ureterolithiasis

formation of stones in the ureter

anatomy of the nephron

glomerulus, proximal convoluted tubule, loop of nephron, distal convoluted tubule, collecting ducts

cystocele

herniation of the bladder into the vagina

nocturnal polyuria

increased urination at night

acute glomerulonephritis

inflammation of the capillary loops of the renal glomeruli -develops suddenly from excess immunity response within kidney tissues -cause is usually infectious

urethritis

inflammation of the urethra -STI is most common cause -usually resolves spontaneously (unless STI is detected; then antibiotics are prescribed)

pre op of TURP

insert urinary catheter; antibiotics

intravesical

inside the bladder

intracorporeal

inside the body

internal urethral sphincter

is smooth detrusor muscle of the bladder neck and elastic tissue that helps to control the exit of urine

Do not palpate a patient with suspected abdominal tumor or aneurysm because

it may harm the patient

pruritus

itching

activated vitamin D

kidney parenchyma; promotes absorption of calcium in the GI tract

Erythropoietin

kidney parenchyma; stimulates bone marrow to make RBCs

uremic frost

layer of urea crystals from evaporated sweat; may appear on the face, eyebrows, axillae, and groin in patients with advanced uremic syndrome

AV graft

looped plastic tubing tunneled beneath the skin, connecting an artery and a vein -forearm -upper arm -inner thigh -1 to 3 weeks after surgery for initial use

urothelial cancer

malignant tumors of urothelium, lining of transitional cells in kidney, renal pelvis, ureters, urinary bladder and urethra -"bladder cancer" -exposure to toxins increases risk -greatest risk factor is tabacco use

ureteroplasty

surgical repair of the ureter

urodynamic studies

measure various aspects of the process of voiding and are used along with other procedures to evaluate problems with urine flow

renal tubules

microscopic tubes in the kidney where urine is formed after filtration

calcium oxalate stones

most common type of kidney stone -decrease sodium intake

stricture

narrowing of the urinary tract

urinalysis glucose

negative -Presence reflects hyperglycemia or a decrease in the kidney threshold for glucose.

urinalysis casts

none -Increased indicates bacteria, protein, or urinary calculi.

urinalysis crystals

none -Presence may indicate that the specimen has been allowed to stand.

urinalysis ketones

none -Presence occurs with diabetic ketoacidosis, prolonged fasting, and anorexia nervosa.

urinalysis parasites

none -Presence of Trichomonas vaginalis indicates infection, usually of the urethra, prostate, or vagina.

urinalysis bilirubin

none -Presence suggests liver or biliary disease or obstruction.

urinalysis nitrates

none -Presence suggests urinary Escherichia coli.

urinalysis leukocyte esterase

none -Presence suggests urinary tract infection.

azotemia

urea in the blood

frequency

urge to urinate frequently in small amounts

dysuria

pain or burning with urination

hematuria

presence of RBCs in the urine; blood in the urine

pyruia

presence of WBCs in the urine

bacteriuria

presence of bacteria in the urine

urolithiasis

presence of calculi (stones) in urinary tract -most common associated condition is dehydration

cystourethroscopy

procedure to view the urinary bladder and the urethra

cystocopy

process of visually examining the urinary bladder with an endoscope

dietary restrictions needed for severe CKD

protein, fluid, potassium, sodium, phosphorus

cystourethrography

radiographic imaging of the bladder and the urethra

acute kidney injury

rapid reduction in kidney function resulting in failure to maintain waste elimination, fluid and electrolyte balance, and acid-base balance -occurs over a few hours or days -reduced perfusion to kidneys, damage to kidney tissue, obstruction of urine outflow

aldosterone

released from adrenal cortex; promotes sodium reabsorption and potassium secretion in DCT and CD; water and chloride follow sodium movement

Vasopressin (ADH)

released from posterior pituitary; makes DCT and CD permeable to water to maximize reabsorption and produce a concentrated urine

radical cystectomy

removal of the bladder and surrounding tissue

Monitor the patient to recognize hypotension. If hypotension or excessive diuresis (e.g., unanticipated urine output 500 to 1000 mL greater than intake over 12 to 24 hours or other goal for intake and output) is present,

respond by notifying the nephrology health care provider because hypotension reduces perfusion and oxygen to the new kidney, threatening graft survival.

acute pyelonephritis

results from bacterial infection with or without obstruction or reflux

oliguria

scant urine output

external urethral sphincter

skeletal muscle that surrounds the urethra and helps to control the exit of urine

benign prostatic hypertrophy

slow enlargement of the prostate gland that can compress the urethra

Teach patients with mild chronic kidney disease (CKD) that carefully managing fluid volume, blood pressure, electrolytes, and other kidney-damaging diseases by following prescribed drug and nutrition therapies can

slow progression to end-stage kidney disease (ESKD).

stent

small tube that is placed in the ureter by ureteroscopy to dilate the ureter and enlarge the passageway for the stone or stone fragments

aldosterone stimulate the distal convoluted tubules to reabsorb

sodium and secrete potassium; that extra sodium increases water reabsorption and increases blood volume and BP, returning BP to normal

dialysate

solution used in dialysis that contains a balanced mix of electrolytes and water and that closely resembles human plasma

urinalysis odor

specific aroma, similar to ammonia -Foul smell indicates possible infection, dehydration, or ingestion of certain foods or drugs.

bacteremia

spread of the infection from the urinary tract to the bloodstream

calculi

stone formation

lithotripsy

surgical crushing of a stone

nephrectomy

surgical removal of the kidney

renal colic

term used to describe the sever flank pain resulting from stones

continence

the ability to voluntarily control emptying of the bladder or colon

uremia

the buildup of nitrogenous waste products in the blood (azotemia)

mixed incontinence

the combination of stress incontinence and urge incontinence

elimination

the excretion of waste from the body of the GI tract (as feces) and kidneys (as urine)

incontinence

the involuntary loss of urine or stool

peritoneal dialysis

the lining of the peritoneal cavity acts as the filter to remove waste from the blood

urethral meatus

the opening at the endpoint of the urethra

renal threshold

the point at which the kidney is overwhelmed with glucose and can no longer reabsorb; also called transport maximum

proteinuria

the presence of protein in the urine

microalbuminuria

the presence of very small amounts of albumin in the urine that are not measurable by usual urinalysis procedures

hemodialysis

the process by which waste products are filtered directly from the patient's blood

nephrostomy

the surgical creation of an opening directly into the kidney; performed to divert urine externally and prevent further damage to the kidney when a stricture is causing hydronephrosis and cannot be corrected with urologic procedures

kidney biopsy

the surgical removal of a small sample of kidney tissue, typically using a special needle inserted through the skin, in order to diagnose conditions such as cancer

Report the presence of glucose or proteins in the urine of a patient undergoing a screening examination to the primary health care provider because

this is an abnormal finding and requires further assessment.

renin converts angiotensinogen (from the liver)

to angiotensin I

bowman capsule

top part of the nephron that encloses the glomerulus

Women from some cultures or religions may have undergone female circumcision. This procedure alters the appearance of the vulvar-perineal area and increases the risk for

urinary tract infections. It also makes urethral inspection or catheterization difficult. Document any noted anatomic changes and ask the patient to describe hygiene practices for this area.

chronic pyelonephritis

usually occurs with structural deformities, urinary stasis, obstruction, or reflux

VCUG (voiding cystourethrogram)

x-ray image (with contrast) of the urinary bladder and urethra obtained while the patient is voiding

intravenous urography

x-ray with radiopaque dye; use to visualize abnormalities in renal system -assess patient for allergies to iodine, seafood, radiopaque dyes, -contraindicated with pregnant women -caution if asthma, cardiac disease and renal insufficiency

urinalysis color

yellow -Dark amber indicates concentrated urine. -Very pale yellow indicates dilute urine. -Dark red or brown indicates blood in the urine. Brown may indicate increased bilirubin level. Red also may indicate the presence of myoglobin. -Other color changes may result from diet or drugs.

retrograde procedures

·Goes against the normal flow of urine ·Contrast agent inserted into lower urinary tract ·Monitor patient for infection, ABCs, change in vitals

signs and symptoms of renovascular disease

• Significant, difficult-to-control high blood pressure • Poorly controlled diabetes or sustained hyperglycemia • Elevated serum creatinine • Decreased glomerular filtration rate (GFR)

habit training

• Assess the patient's 24-hour voiding pattern for 2 to 3 days. • Base the initial interval of toileting on the voiding pattern (e.g., 2 hours). • Help the patient to the toilet or provide a bedpan/urinal every 2 hours (or whatever has been determined to be an appropriate toileting interval for the individual patient). • During the toileting, remind the patient to void and provide cues such as running water. • If the patient is incontinent between scheduled toileting, reduce the time interval by 30 minutes until the patient is continent between voidings. • Help the patient to toilet and prompt to void at prescribed intervals. • Do not leave the patient on the toilet or bedpan for longer than 5 minutes. • Ensure that all nursing staff members comply with the established toileting schedule and do not apply briefs or encourage the patient to "just wet the bed." • Reduce toileting interval by 30 minutes if there are more than two incontinence episodes in 24 hours. • If the patient remains continent at the toileting interval, attempt to increase the interval by 30 minutes until a 3- to 4-hour continence interval is reached. • Praise the patient for successes and spend extra time socializing with the patient. • Discuss daily record of continence with staff to provide reinforcement and encourage compliance with toileting schedule. • Include assistive personnel in all aspects of the habit training.

bladder training

• Assess the patient's awareness of bladder fullness and ability to cooperate with training regimen. • Assess the patient's 24-hour urine elimination pattern for 2 to 3 consecutive days (bladder diary). • Base the initial interval of toileting on the voiding pattern (e.g., 45 minutes). • Teach the patient to void every 45 minutes on the first day and to ignore or suppress the urge to urinate between the 45-minute intervals. • Take the patient to the toilet or remind him or her to urinate at the 45-minute intervals. • Provide privacy for toileting and run water in the sink to promote the urge to urinate at this time. • If the patient is not consistently able to resist the urge to urinate between the intervals, reduce the intervals by 15 minutes. • Continue this regimen for at least 24 hours or for as many days as it takes for the patient to be comfortable with this schedule and not urinate between the intervals. • When the patient remains continent between the intervals, increase the intervals by 15 minutes daily until a 3- to 4-hour interval is comfortable for the patient. • Praise successes. If incontinence occurs, work with the patient to re-establish an acceptable toileting interval.

prevention of kidney and urinary problems

• Be alert to the general appearance of your urine. Note any changes in its color, clarity, or odor. • Changes in the frequency or volume of urine passage occur with changes in fluid intake. More frequent or infrequent voiding not associated with changes in fluid intake may signal health problems. • Any discomfort or distress with the passage of urine is not normal. Pain, burning, urgency, aching, or difficulty with initiating urine flow or complete bladder emptying is of some concern. Report such symptoms to your primary health care provider. • The kidneys need 1 to 2 L of fluid a day to flush out your body wastes. Water is the ideal flushing agent. • Avoid sugary, high-calorie drinks; they provide low-quality calories that contribute to weight gain and sugar-induced urination. • Changes in kidney function are often silent for many years. Periodically ask your primary health care provider to measure your kidney function with a blood test (serum creatinine) and a urinalysis. • If you have a history of kidney disease, diabetes mellitus, or hypertension (high blood pressure) or a family history of kidney disease, you should know your serum creatinine level and your glomerular filtration rate (either estimated from serum creatinine or measured with a 24-hour creatinine urine collection). At least one checkup per year that includes laboratory blood and urine testing of kidney function is recommended. • If you are identified as having decreased kidney function, ask about whether any prescribed drug, diagnostic test, or therapeutic procedure will present a risk to your current kidney function. Evaluate the contribution of diet to risk for kidney disease with your primary health care provider or a registered dietitian nutritionist. Check out all nonprescription drugs with your primary health care provider or pharmacist before using them.

caring for the patient with an arteriovenous fistula or arteriovenous graft

• Do not take blood pressure readings using the extremity in which the vascular access is placed. • Do not perform venipunctures or start an IV line in the extremity in which the vascular access is placed. • Palpate for thrills and auscultate for bruits over the vascular access site every 4 hours while the patient is awake. • Assess the patient's distal pulses and circulation in the arm with the access. • Elevate the affected extremity after surgery. • Encourage routine range-of-motion exercises. • Check for bleeding at needle insertion sites. • Assess for indications of infection at needle sites. • Instruct the patient not to carry heavy objects or anything that compresses the extremity in which the vascular access is placed. • Instruct the patient not to sleep with his or her body weight on top of the extremity in which the vascular access is placed.

preventing a UTI

• Drink fluid liberally, as much as 2 to 3 L daily if not contraindicated by health conditions. • Be sure to get enough sleep, rest, and nutrition daily to maintain immunologic health. • If spermicides are used, consider changing to another method of contraception. • [For women] Clean your perineum (the area between your legs) from front to back. • [For women] Avoid using or wearing irritating substances such as douches, scented lubricants for intercourse, bubble bath, tight-fitting underwear, and scented toilet tissue. Wear loose-fitting cotton underwear. • [For women] Empty your bladder before and after intercourse. • [For both women and men] Gently wash the perineal area before intercourse. • Do not routinely delay urination because the flow of urine can help remove bacteria that may be colonizing the urethra or bladder. • If you experience burning when you urinate, if you have to urinate frequently, or if you find it difficult to begin urinating, notify your primary health care provider right away, especially if you have a chronic medical condition (e.g., diabetes) or are pregnant.

signs and symptoms of acute pyelonephritis

• Fever • Chills • Tachycardia and tachypnea • Flank, back, or loin pain • Tenderness at the costovertebral angle (CVA) • Abdominal, often colicky, discomfort • Nausea and vomiting • General malaise or fatigue • Burning, urgency, or frequency of urination • Nocturia • Recent cystitis or treatment for urinary tract infection (UTI)

secondary glomerular diseases and symptoms

• Systemic lupus erythematosus (SLE) • Sustained liver disease (hepatitis B or C, autoimmune hepatitis, and cirrhosis) • Amyloidosis • Mesangiocapillary glomerulonephritis (MCGN) • Alport syndrome • Vasculitis • Goodpasture syndrome • IgA nephropathy • Wegener granulomatosis • HIV-associated nephropathy • Diabetic glomerulopathy

complicated cystitis symptoms

• Fever • Chills and rigors • Nausea or vomiting • Malaise • Flank pain and costovertebral angle tenderness Symptoms That May Occur in the Older Adult • Sudden or worsening: dysuria, urinary incontinence, nocturia, urgency, and frequency. A general sense of lack of well-being. • Note: Changes in mental status and falls are not reliable predictors of UTIs. These changes need to be fully assessed to determine the underlying cause.

patient teaching for urinary calculi

• Finish your entire prescription of antibiotics to ensure that you will not get a urinary tract infection. • You may resume your usual daily activities. • Remember to balance regular exercise with sleep and rest. • You may return to work 2 days to 6 weeks after surgery, depending on the type of intervention, your personal tolerance, and your primary health care provider's directives. • Depending on the type of stone you had, you may be advised to take medications or adjust your diet may to reduce the risk for further stone formation. • Remember to drink at least 3 L of fluid a day to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. • Monitor urine pH as directed (possibly up to three times per day). • Expect bruising after lithotripsy. The bruising may be quite extensive and may take several weeks to resolve. • Your urine may be bloody for several days after surgery. • Pain in the region of the kidneys or bladder may signal the beginning of an infection or the formation of another stone. Report any pain, fever, chills, or difficulty with urination immediately to your primary health care provider or nurse. • Keep follow-up appointments to check on infection and have repeat cultures done.

UTI common symptoms

• Frequency • Urgency • Dysuria • Suprapubic pain or tenderness, low back pain • Nocturia • Incontinence • Hematuria • Pyuria • Bacteriuria • Retention • Suprapubic tenderness or fullness • Feeling of incomplete bladder emptying

infectious agents associated with glomerulonephritis

• Group A beta-hemolytic Streptococcus • Staphylococcal or gram-negative bacteremia or sepsis • Pneumococcal, Mycoplasma, or Klebsiella pneumonia • Syphilis • Dengue • Hantavirus • Varicella • Parvovirus • Hepatitis B and C • Cytomegalovirus • Parvovirus • Epstein-Barr virus • Human immunodeficiency virus

signs and symptoms of chronic pyelonephritis

• Hypertension • Inability to conserve sodium • Decreased urine-concentrating ability, resulting in nocturia • Tendency to develop hyperkalemia and acidosis

patient education for urinary incontinence

• Maintain a normal body weight to reduce the pressure on your bladder. • Do not try to control your incontinence by limiting your fluid intake. Adequate fluid intake is necessary for kidney function and health maintenance. • If you have a catheter in your bladder, follow the instructions given to you about maintaining the sterile drainage system. • If you are discharged with a suprapubic catheter in your bladder, inspect the entry site for the tube daily, clean the skin around the opening gently with warm soap and water, and place a sterile gauze dressing on the skin around the tube. Report any redness, swelling, drainage, or fever to your primary health care provider. • Do not put anything into your vagina, such as tampons, drugs, hygiene products, or exercise with weights, until you check with your primary health care provider at your 6-week checkup after surgery. • Do not have sexual intercourse until after your 6-week postoperative checkup. • Do not lift or carry anything heavier than 5 lb or participate in any strenuous exercise until your primary health care provider gives you postoperative clearance. In some cases, this could be as long as 3 months. • Avoid exercises, such as running, jogging, step or dance aerobic classes, rowing, cross-country ski or stair-climber machines, and mountain biking. Brisk walking without any additional hand, leg, or body weights is allowed. Swimming is allowed after all drains and catheters have been removed and your incision is completely healed. • If Kegel exercises are recommended, ask your nurse for specific instructions.

Caring for the Patient With a Peritoneal Dialysis Catheter

• Mask yourself and your patient. Wash your hands. • Put on sterile gloves. Remove the old dressing. Remove the contaminated gloves. • Assess the area for signs of infection, such as swelling, redness, or discharge around the catheter site. • Use aseptic technique: • Open the sterile field on a flat surface and place two precut 4 × 4-inch gauze pads on the field. • Place three cotton swabs soaked in povidone-iodine or other solution prescribed by the nephrology health care provider on the field. Put on sterile gloves. • Use cotton swabs to clean around the catheter site. Use a circular motion starting from the insertion site and moving away toward the abdomen. Repeat with all three swabs. • As an alternative (if recommended by the nephrology health care provider or clinic), cleanse the area with sterile gauze pads using soap and water. Use a circular motion starting from the insertion site and moving away toward the abdomen. Rinse thoroughly. • Apply precut gauze pads over the catheter site. Tape only the edges of the gauze pads.

signs and symptoms of nephrotic syndrome

• Massive proteinuria • Hypoalbuminemia • Edema (especially facial and periorbital) • Lipiduria • Hyperlipidemia • Delayed clotting or increased bleeding with higher-than-normal values for serum activated partial thromboplastin time (aPTT), coagulation, or international normalized ratio for prothrombin time (INR, PT) • Reduced kidney function with elevated blood urea nitrogen (BUN) and serum creatinine and decreased glomerular filtration rate (GFR)

patient education for polycystic kidney disease

• Measure and record your blood pressure daily and notify your primary health care provider about consistent changes in blood pressure. • Take your temperature if you suspect you have a fever. If a fever is present, notify your physician or nurse. • Weigh yourself every day at the same time of day and with the same amount of clothing; notify your primary health care provider or nurse if you have a sudden weight gain. • Limit your intake of salt to help control your blood pressure once hyperfiltration is no longer a symptom of your disease (once chronic kidney disease [CKD] is present). • Notify your primary health care provider or nurse if your urine smells foul or has a new occurrence of blood in it. • Notify your primary health care provider or nurse if you have a headache that does not go away or if you have visual disturbances because these are symptoms of a stroke or bleeding in the brain. • Monitor bowel movements to prevent constipation.

signs and symptoms of uremia

• Metallic taste in the mouth • Anorexia • Nausea • Vomiting • Muscle cramps • Uremic frost on skin • Fatigue and lethargy • Hiccups • Edema • Dyspnea • Paresthesia

Caring for the Patient Undergoing Hemodialysis

• Weigh the patient before and after dialysis. • Know the patient's dry weight. • Discuss with the nephrology health care provider or pharmacist whether any of the patient's drugs should be withheld until after dialysis. • Be aware of events that occurred during previous dialysis treatments. • Measure blood pressure, pulse, respirations, and temperature. • Assess for indications of orthostatic hypotension. • Assess the vascular access site when taking vital signs and follow agency policy for central line care and dressing changes. • Observe for bleeding at the vascular access site and other sites where skin integrity is disrupted because anticoagulants given during dialysis and the presence of uremia increase bleeding risk. • Assess the patient's level of consciousness. • Assess for headache, nausea, and vomiting. • Assess serum laboratory tests to evaluate effectiveness of treatment in removing wastes and achieving desired outcomes (e.g., fluid and electrolyte balance, reduction of uremia)

managing fluid volume

• Weigh the patient daily at the same time each day, using the same scale, with the patient wearing the same amount and type of clothing, and graph the results. • Observe the weight graph for trends (1 L of water weighs 1 kg). • Accurately measure all fluid intake and output. • Teach the patient and family about the need to keep fluid intake within prescribed restricted amounts and to ensure that the prescribed daily amount is evenly distributed throughout the 24 hours. • Monitor for these symptoms of fluid overload at least every 4 hours during critical illness: • Decreased urine output • Rapid, bounding pulse • Rapid, shallow respirations • Presence of dependent edema • Auscultation of crackles or wheezes • Presence of distended neck veins in a sitting position • Decreased oxygen saturation • Elevated blood pressure • Narrowed pulse pressure • Assess level of consciousness and degree of cognition. • Ask about the presence of headache or blurred vision.