Renal, NUR 202

*key features of acute and chronic pyelonephritis* Can be the same as cystitis (UTI)

*Acute* - fever - chills - tachycardia and tachypnea - flank, back, or loin pain - tender costal vertebral angle (CVA) - abdominal, often colicky, discomfort - nausea and vomiting - general malaise or fatigue - burning, urgency, or frequency of urination - nocturia -Pt may develop sepsis -affects the kidneys and can lead to kidney failure *Chronic* -related to renal function decline -hypertension -nocturia -hyperkalemia and acidosis -excessive thirst -weight loss *-inability to concentrate urine, leads to nocturia* *-inability to conserve sodium* -can lead to uremia, HTN and calculi formation -can lead to renal failure and ESRD -tendency to develop hypercalcemia and acidosis -patients with renal failure watch phosphorus(should avoid because they have to much phosphorus) to get calcium up (milk is high in phosphorus) ***In chronic pyelonephritis, bacteria may be absent with higher levels of protein in the urine. A positive leukocyte esterase (an enzyme released by bacteria) indicates pyuria *_-look on black board for renal handout on diet_* ***Need to know foods & where electrolytes come from* -Diagnose the same as the other renal problems ***in addition Diagnostic •Radiologic imaging and histologic testing (rather than clinical features) •Images reveal a small, contracted kidney with a thinned parenchyma •Collecting system may be small or hydronephrotic •Pathologic analysis reveals loss of functioning nephrons, infiltration of the parenchyma with inflammatory cells, and fibrosis *NURSING* -Pain management -Antibiotics *Acute interventions - non-surgical* -Pain management -drug therapy: Antibiotics (broad spectrum filling culture results) -urinary antiseptics: (macrobid) taken with milk, may produce brown/orange urine, caution with renal impairment, monitor flu-like symptoms in elderly & those with pulmonary dz,

*Pyelonephritis (Upper UTI)*

*Acute*(upper urinary tract infection)- an active bacterial infection of the renal pelvis, medulla, calyces, tubules and interstital tissue of one or both kidneys parenchyma and collecting system. Due to bacterial infection usually. *Chronic*(AKA interstitial nephritis, chronic atrophic pyelonephritis or reflux nephropathy- which is when scarring occurs in the presence of vesicoureteral reflux) Contraction of kidney & dtysfunctioning nephrons. The ureters are narrowed. Kidneys are small, atrophic, and shrunken and lose function due to permanent renal tissue scarring or fibrosis- low grade fever, asymptomatic disease that leads to renal damage (Interstitial nephritis). Results from repeated or continued upper urinary tract infections = scar tissue, changing blood vessel, glomerular, and tubular structure. They are more likely to develop kidney failure. *Causes are the same as UTI, vesicoureteral reflux's (VUR) is a big cause due to congenital defect or pressure that causes the vesicoureteral orfice to fail, valve failure)VU Reflux, individual that has spinal cord injury* *Also can be caused by bladder outlet obstruction. A kidney stone that causes pressure and the valve opens, pushing flow up)*

*Urolithiasis (kidney stones) Role of nurse*

*Assessment: clinical manifestations* -Pain: renal colic(flank pain, suggests that the stone is in the kidney or upper ureter) (Flank pain that extends towards the abdomen or to the scortum and vagina suggest the stone is in the ureters or bladder) make sure patient has around the clock medications. -hematuria: from stones moving through tissue and damaging -Watch I/O - Strain Urine and send stones to lab -Monitor for UTI -Maintain fluids: 3-4 L a day (unless restricted) -COMPLICATION - Hydronephrosis: is the swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction, fluid collects in renal pelvis and tissues, thus causing the kidney to swell. Hydronephrosis can occur in one or both kidneys. The main function of the urinary tract is to remove wastes and fluid from the body. Fluid puts pressure on kidney and leads to renal failure from the blockage and the urine buildup. -Nausea and vomiting -Pallor and diaphoresis (sweating) -Low grade temp -flank pain: kidney, upper urethra -pain radiating to abdomen or scrotem: ureter or bladder *Assess* -for bladder distention -appearance of: pale ashen diaphoretic excruciating pain vital signs may be elevated with pain body temp and pulse elevated with infection BP will decrease if pain causes shock

*Renal Trauma*

*Bruising to the kidney* -Rest -vit k -whole blood if needed -packed RBC -monitor urine output -Minimal output on regular floor is 30cc -on CCU floor or for traumas .5 cc hr per kg

*Urolithiasis (kidney stones) -Prevention of Obstruction and nutritional considerations* pg 1365

*Drug selection to prevent obstruction depends on what is forming the stone:* *Calcium* -diuretics -hydrochlorothiazide, promote calcium reabsorption (this is what book states) *Oxialate* -allopurinol - this is a gout medication, however the same mineral that forms gout is responsible for forming this type of stone. *Uric acid* -allopurinol -sodium bicarbonate - low sodium diet can help decrease calcium formation in this type of stone. *Cystine* -captopril -lowers cystine levels *STATIN drugs have also been found to reduce stone formation* *FLUIDS - high intake of fluids 3 L a day* *Nutrition* (page 1366 table 66-5) *low sodium* -increases calcium reabsorption *Low protein* Uric acid (urate) -avoid meats such as organ meats, poultry, fish, gravies, red wines and sardines *cystine* -avoid animal protein *Lemons* -increase concentration of citrates which term-114decrease stone formation -4 oz/2liters (500ml every 4 ours while awake and 750ml at night) of water a day *Struvite, (magnesium ammonium phosphate) -limit high-phosphate foods, such as dairy products organ meats and grains. *Calcium phosphate* -Limit intake of foods with high animal protein to 5 -7 servings per week and never more than 2 a day. reduce calcium intake, milk and dairy products. *Calcium oxalate* -avoid oxalate sources, such as spinach, black tea and rhubarb

*treatment of pyelonephritis*

*Drug therapy* - antibiotics to treat infection. At first, broad spectrum, then more specific - urinary antiseptic drugs macrobid(macrodantin):taken with milk, may produce brown/orange urine, caution with renal impairment, monitor flu-like symptoms in elderly & those with pulmonary dz, liquid will stain teeth so rinse mouth. *Nutrition therapy* - adequate calories from all food groups - fluid intake of 2-3 L/day *Surgical* - pyelolithotomy: stone removal, esp for large stones through incision in back - nephrectomy: removal of kidney. Last resort when other measures fail *ureteral diversion* - reimplantation of ureter (through another site in the bladder wall) - ureteroplasty (ureter repair or revision) - preserves kidney function and helps eliminates infection

*Urolithiasis (kidney stones) presence of calculi in kidneys* pg 1361

*Formed by 3 conditions:* -Slow urine flow resulting in supersaturation of urine w/ particular element (calcium) that becomes crystalized -damage to the lining of the urinary tract -decrease in the amount of inhibitor substance *Types of Stones* *Calcium Oxalate:* Most common forms in acidic urine due to an increase the amounts of calcium and oxalate in urine. Causes of increased calcium: hypercalcemia, medications, hyperthyroidism(releases excess calcium), increase intake of sodium Na+(sodium prevents calcium from being reabsorbed into blood stream and allot of calcium is left in nephron). Oxalates: Oxalates are normally excreted in stool. Gi disorders cause increase. Ulcerative colitis and Chrohns. There is an issue with absorption and calcium binds to fats and this leaves oxalates by themselves and it goes into the urine instead of leaving through the stool. Also high intake of oxalates in food can cause this problem. Food that increases oxlates: spinach, black tea, rhubarb *Uric Acid* Too much uric acid in urine and a low ph. This can be caused by gout, dehydration, high intake of purine, diabetes and food intake high in purine and animal protein. Food that increases purine: alcoholic beverages (mainly red wine), anchovies, sardines, cod, trout, bacon, turkey, veal, venison, organ meats Foods that increase uric acid: almonds, cashews, coca powder, okra, sweet potatoes, bran cereals, raspberries, stevia, french fries *Cystine:* forms to much amino acids "cystine" in urine. This is a very rare kidney stone and normally cause by genetic deformity. The proximal convoluted tubule normally filters 100% of amino acids, in this defect it does not and leaves amino acids in urine, that form stones. Food that increases cystitis: pork, beef, chicken, fish, lentils, oatmeal, eggs, low fat yogurt, sunflower seeds, cheese *S

*Other Common Problems Affecting the Testes and Adjacent Structures:*

*Hydrocele* Cystic mass is usually filled with straw- colored fluid that forms around the testis resulting from impaired lymphatic drainage of the scrotum, causing a swelling of the tissue surrounding the testes. Hydrocele may be drained via needle and syringe or it may be removed surgically. *Spermatocele* A sperm-containing cyst develops on the epididymis alongside the testicle. Normally, spermatoceles are small and asymptomatic, and require no interventions. If they become large enough to cause discomfort, a spermatocelectomy is performed. *Varicocele* A cluster of dilated veins occur behind and above the testis. Varicoceles can also cause infertility. Varicocelectomy is performed through an inguinal incision in which the spermatic veins are ligated in the cord. - After surgery use a rolled towel under scrotum to promote drainage - Apply ice for swelling *Scrotal Torsion* Torsion of the testes involves twisting of the spermatic cord and occurs most often during puberty. Because the testes are sensitive to any decrease in blood flow, torsion of the testis is a surgical emergency. Surgical intervention may be required. *Cryptorchidism* Results when the testicles fail to descend; mainly a pediatric problem - Increase risks of? Injections of B-HCG luteinizing hormone- releasing hormone or testosterone optional to promote descent of the testicles Orchidopexy surgical procedure optional *Cancer of the Penis* Epidermoid (squamous) carcinomas developing from squamous cells - Fewer than 1% seen in US Circumcision in infancy—almost always eliminates the possibility of penile cancer Usually seen as a painless wartlike growth or ulcer Excisional biopsy Radiation therapy -gi symptoms will follow as well as lower immune system and possibility of radiation burns. limit spicy or fatty foods, caffeine, and da

*pyelonephritis (Upper UTI)* Involves Renal parenchyma, Pelvis, Ureters Pyelo (=pelvis) Neph (=kidney) Itis (=inflammation) (RENAL PELVIC INFECTION- funnel like structure that drains urine into the ureter)

*INFLAMED Kidney* *Bacterial infection in the kidney and renal pelvis* - the upper urinary tract. - either the presence of active organisms in the kidney or the effects of kidney infection - acute: pregnancy, obstruction and reflux - chronic: structural deformity, obstruction with reflux - organisms move up from the lower urinary tract into the kidney tissue. - acute: involves acute tissue inflammation, tubular cell necrosis, and possible abscess formation - chronic: reflux of infected urine is most common cause. Contraction of the kidney & dysfunctioning nephrons, scar tissue. Ureters fibrotic and narrowed. -Can lead to renal failure RESULTING IN: *HTN, poor urine-concentration, pyuria (condition that occurs when excess white blood cells, or pus, are present in the urine), proteinuria and azotemia (is a medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood)

*Labs, treatment of ARF acute renal failure*

*Labs* -BUN and Creatinine *GFR not used in acute failure* -elevated BUN can indicate something other than kidney failure. Ex dehydration -a decreased BUN could indicate liver failure, malnutrition and over hydration *What are the Labs and what do they do* -*Creatinine*: is a waste product from muscle breakdown and is solely filtered from the bloodstream via the glomerulus and is NOT reabsorbed or secreted within the nephron. Therefore, the rate of filtration of creatinine by the glomerulus helps us to determine the efficiency of the kidneys, which is why we collect blood levels to measure creatinine levels. Normal Creatinine level 0.6-1.1 mg/dL Creatinine will increase due to drugs which prevent secretion(cimetidine) and low GFR- main cause Creatinine will decrease with profound muscle wasting. -*Glomerular Filtration Rate*: rate of blood flow through the kidneys (ml/min). This shows how well the glomerulus is filtering the blood....great for determining kidney function. Normal GFR in adults: 90 or higher ml/min (remember this depends on the patient's age, weight, creatinine, sex, and race) Normal GFR = normal urine output, normal BUN and creatinine, normal electrolyte and water balance Decreased GFR = low urinary output along with an increase in waste products in the blood (creatinine and BUN), electrolyte/fluid imbalances, and buildup of fluid -*BUN (blood urine nitrogen)*: urea (measured as blood urea nitrogen) is a waste product from protein breakdown in the liver.(end product of muscle breakdown) It is secreted in the blood and filtered out through the kidneys. Normal BUN: 6-20 mg/dL (in AKI this level becomes greater than 20 mg/dL) BUN will increase due to: fever, GI bleed, Steroids, catabolic state, dehydration BUN will decrease due to liver failure, malnutrition and over hydration *Albumin* Main

*Urolithiasis (kidney stones) Labs, Meds and Nutrition*

*Labs* -Urine: urinalysis (Will see blood, WBC,RBC pus bacteria) -culture and sensitivity test KUB(X rays of the kidney, ureter, bladder) -CT scan (if stone can't be visualized) -IVP: x-ray with dye *-24 hour urine: MUST be kept on ice* *Meds* Pain>>give opioids, and spasmolytic agents, DRUGS THERAPY: -NSAIDS: Non-steroidal anti-inflammatory drugs -Spasmolytic drugs: (anaspas and cystopaz) important for relief of pain *If having lithotripsy shock treatment, cannot use non-steroidal ****Combo of thiazide, diuretic and allopurinol with fluid intake can aid in expulsion* MOVEMENT(MOVEMENT HELPS MOVE STONES ALONG)

*manifestations and diagnostics of RCC* Renal Cell Carcinoma

*Manifestations* - only 5-10% experience flank pain, obvious blood in the urine (LATE FINDING) and palpable kidney mass - dull, aching pain or intense if bleeding in tumor/kidney - weight loss, muscle wasting, weakness - pallor, darkening of nipples - gynecomastia *Systemic effects* -Anemia -Hypercalctermemia -liver dysfunction -hormonal effects -Incresed ESR hypertension *Diagnostics* - urinalysis & blood studies - surgical exploration - IV urogram with nephrogram, CT, sonogram, MRI - biopsy From Evolve: Assessment findings the nurse expects to assess in a client with kidney cancer include: erythrocytosis, hypercalcemia, hepatic dysfunction, and increased sedimentation rate. Erythrocytosis alternating with anemia and hepatic dysfunction with elevated liver enzymes may occur with kidney cancer. Parathyroid hormone produced by tumor cells can cause hypercalcemia. An elevation in sedimentation rate may occur in paraneoplastic syndromes.

*key features of severe chronic kidney disease* (chart in med surge book)

*Neurological* - lethargy and daytime drowsiness - inability to concentrate, decreased attention span - seizures, coma, slurred speech, asterixis - tremors, twitching, or jerky movements - myoclonus, ataxia, paresthesias *Cardiovascular* - cardiomyopathy, hypertension - peripheral edema, heart failure - uremic pericarditis - pericardial effusion and friction rub - cardiac tamponade *Respiratory* - uremic halitosis, tachypnea - deep sighing, yawning, kussmaul's resp (metabolic acidosis) - uremic pneumonitis, SOB - pulmonary edema, pleural effusion - depressed cough reflex, crackles *Hematologic* - anemia, abnormal bleeding and bruising ~ GI - anorexia, n/v, metallic taste in mouth - changes in taste acuity and sensation - uremic colitis (diarrhea), constipation - uremic gastritis (possible GI bleeding) - uremic fetor (breath odor) - stomatitis, diarrhea *Urinary* - polyuria, nocturia (early), oliguira, anuria (later), hematuria, proteinuria - diluted, strawlike appearance *Integumentary* - decreased skin turgor, dry skin - yellow-grterm-127ay pallor - pruritus, ecchymosis, purpura - soft-tissue calcifications - uremic frost (late, premorbid) *Musculoskeletal* - muscle weakness and cramping - bone pain, pathologic fractures - renal osteodystrophy *Reproductive* - decreased fertility, decreased libido - infrequent or absent menses, impotence

*phases of ARF Acute renal failure*

*Onset Phase* - begins with precipitating event and continues until oliguria(output of urine less than 400ml a day in adults) develops - lasts hours to days - gradual accumulation of nitrogenous wastes (creatinine, BUN) may be noted *Oliguric Phase* - urine output of 100-400 ml/24hr that does NOT respond to fluid challenges or diuretics - lasts 1-3 weeks - increasing creatinine, BUN, hyperkalemia, bicarbonate deficit, hyperphosphatemia, hypocalcemia, hypermagnesemia - sodium retention occurs but masked by dilutional effects of water retention -metabolic acidosis can occur in this phase *Diuretic phase (highest output phase)* - sudden onset within 2-6 weeks after oliguric stage - urine flow increases rapidly over several days - diuresis can be up to 10 L/day - electrolyte losses typically precede clearance of nitrogenous wastes - BUN level starts to fall until reaches normal or a plateau - normal renal tubular function is re-established in the phase -dehydration occurs -hypovolemia can occur *Recovery phase* (convalescent phase) - beings to return to normal activity levels - complete recovery can take 12 months - functions at lower energy level and has less stamina than before illness - residual renal insufficiency may be noted - renal function may never return to normal, but sufficient for long healthy life

*interventions of PKD*

*Pain management* - drugs and complementary approaches (anti hypertension and diuretics) - NSAIDS used cautiously because they reduce renal blood flow to the kidney. - aspirin avoided to reduce bleeding risk - give antibiotics: monitor creatinine levels because it can be nephrotoxic - apply dry heat for comfort - if pain is severe, cysts can be reduced by needle aspiration *Infection prevention* *Bowel management/constipation/stool softeners* *Other important interventions* - maintain adequate fluid intake - increase dietary fiber - exercise regularly -Daily weights and BP checks (increase in weight notify doc) *Hypertension control* - education to promote self management - restrict sodium intake - antihypertensives - diuretics - teach to measure and record BP - daily weights *Prevention of chronic kidney disease* -look at GFR as it drops decrease protein intake -GFR of 30 needs dialysis *Patient education* -patient should record BP and daily weights -Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. -Contact your provider with any visual disturbances

*types of vascular access for hemodialysis* (table 71-9)

*Permanent* - AV fistula: (for long term use)an internal anastomosis of an artery to a vein. Locations: forearm. Initial use: 2-4 months or longer. Complications? Bleeding - AV graft: (for long term use) synthetic vessel tubing tunneled beneath the skin, connecting an artery and a vein. Location: forearm, upper arm, inner thigh. Initial use: 1-2 weeks -central line- ONLY used for dialysis -assess for thrill -auscultate for bruit *shunt and graft take 2 - 4 weeks to mature - Dual-lumen hemodialysis catheter: an extended-use catheter, surgically tunneled under the skin with a barrier cuff. Location: subclavian vein. Initial Use: immediately postoperatively and after x-ray confirmation of placement *Temporary* - hemodialysis catheter (dual or triple lumen): a specially designed catheter with two or three lumens. Two lumens are for blood outflow and inflow for hemodialysis; a third allows venous access without accessing dialysis lumens. Location: subclavian, internal jugular, or femoral vein. Initial use: immediately after insertion and x-ray confirmation of placement - AV shunt (relatively uncommon): an external loop of silastic tubing connecting an artery and a vein. Each section of tubing is sutured into a vessel and brought through a skin stab wound. Location: forearm. Initial Use: immediately after insertion - Subcutaneous device: an internal device with two metallic access ports and two catheters inserted into large central veins. Location: subclavian. Initial Use: immediately after insertion -CVC's are temporary -Should only be used for dialysis Care: -Dsg change with every treatment -Pt and RN must mask Do not use alcohol *Access AVF* Surgical anastomosis of vein and artery *Nursing Considerations* -No blood pressure or blood sticks in extremity with vascular access -Palpate for thrills and auscultate for

*Urine incontinence medications and surgical intervention*

*Petrol/Ditropan (oxybutynin)* teach pt to increase fluids for stress/urge incontinence -anticholergenic -decreases spasms, frequency and urgency -increase bladder capacity *Estrogen Cream* Estrdiol -strengthens pelvic floor and muscle tone *TCA*- strengthens pelvic floor. TCA is with sedative properties, *amitriptyline*(TCA drug) increases the circulating levels of norepinephrine and serotonin by blocking their reuptake at nerve endings. It ineffective for use in urge incontinence but is extremely effective in decreasing symptoms of urinary frequency in women with pelvic floor muscle dysfunction. *Bethanechol Chloride (Urecholine)* -short term cholinergenic -urinary tract stimulant *Surgical intervention* -consent -assess for post-op complications -catheter care -post op ed cath care ***problems with retention after surgery ****make sure your pt is voiding without having =<50 cc of residual (In those who can void, incomplete bladder emptying is diagnosed by post void catheterization or ultrasonography showing an elevated residual urine volume. A volume < 50 mL is normal)

*ARF Acute renal failure key features*

*Prerenal* initial clinical signs - hypotension - tachycardia - decreased cardiac output - decreased central venous pressure - decreased urine output, although occasionally urine output remains normal (this is typically first sign) change in electrolytes *These others increase as it worsens* - lethargy/drowsiness: due to increased BUN -SOB -Fatigued -COnfusion -Nausea and vomiting -chest pain or pressure -seizures/coma in severa patients *Intrarenal ARF and Postrenal* - renal: oliguria or anuria, increased urine specific gravity - cardiac: htn, tachycardia, jvd, increased central venous pressure, ECG changes - respiratory: SOB, orthopnea, friction rub, rales/crackles, pulmonary edema - GI: anorexia, n/v, flank pain - neuro: lethargy, h/a, tremors, confusion drowsiness caused by increased BUN - general: generalized edema, weight gain

*drugs for UTI's and Pyelonephritis* Chart 66-10 pg 1360 shows different drugs than she gave us in class and on powerpoint

*Sulfonamides:* - (trimethoprim/sulfamethoxazole)BACTRIM: main med used NOT used for pyelonephritis. *Used for ACUTE UTI *Take with food and water *Steven Johnson Syndrome: is a rare, serious disorder of your skin and mucous membranes. It's usually a reaction to a medication or an infection. Often, it begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. *If on birth control use other method *Known to crystalize stones so it is important to drink lot's of water while taking. *Can potentiate the effects of coumadin, phenytoin and oral hypoglycemics *Can cause hemolytic anemia, agranulocytosis, leukopenia and ITP (notify MD of sore throat) *Can cause urine to turn dark brown ***pyelThe nurse tells the client with a UTI who is taking trimethoprim/sulfamethoxazole to be certain to wear sunscreen protection clothing, drink at least 3 liters of fluid every day, take the drug with 8 ounces (236 mL) of water, and take all of the drug to get the benefits. Wearing sunscreen and protective clothing is important while taking trimethoprim/sulfamethoxazole, because increased sensitivity to the sun can lead to severe sunburn. Sulfamethoxazole can form crystals that precipitate in the kidney tubules, so fluid intake prevents this complication. clients must be cautioned to take all of the drug that is prescribed for them, even if their symptoms improve or disappear soon, to prevent bacterial resistance and infection recurrence. - septra *quinolones* *- Ciprofloxacin/Levofloxacin (over age 18) - used for pyelonephritis* *broad spectrum *take with food & Water *avoid antacids *can cause cardiac arythmias *Do not crush *Known to crystalize stones so it is important to drink lot's of water while taking. - levaquin - *Penicillins* - possible allergic reaction - amoxicillin *possible allergic

*Urolithiasis (kidney stones) Education* pg 1366 chart 66-11 (this is different from what she taught in class)

*Teach about contributing factor to stone formation* -urinary stasis -urinary retention -immobilization- when you are immobile bones leak calcium & you are higher risk for stone development. -dehydration *Complementary and alternative therapy* -getting urine more alkaline, ex lemonade, citrus drinks -relaxation therapy *Prevention* at least 3-4 L fo fluid a day *Walking* *Warm bath* *Increased risk of infection* - watch for infection while trying to pass stone

*labs for cystitis and pyelonephritis*

*Urinalysis* - performed on a clean-catch midstream specimen -*Urinalysis checks for what?* WBCs <2 RBCs <4 Bacteria: <1000 colonies Protein: <0.8 <80 in 24hr WBC casts: should be none PH<8 BUN, Creatinine and GFR for baseline to watch if kidney's are deteriorating *Urine culture* - confirms type of organisms and the number of colonies ***looking for nitrites and blood - expensive and results take at least 48 hrs -CT, sonography, -cystoscopy: direct visualization of the urethra and bladder through a cystoscope (Post op: pink-tinged urine, record it but no need to call the MD. urine had red blood or clots in it, call MD, should not have decreased urine output) -WBC Casts in urinalysis = pyelonephritis

*S&S of nephrotic syndrome*

*albumin(simple form of protein) in the urine is the first sign* Leaves the blood and goes out through the urine. -albumin in urine is increased but decreased in blood. (hypoalbuminia) -albumin is the sponge that keeps fluids in the vessels. When albumin goes out in urine, plasma shift to interstitial space and it causes major edema & skin may even weep. PITTING EDEMA KEY FEATURE *- massive proteinuria!*** (shouldn't have in urine) This is caused when there is holes in the glomerulus so protein gets through and makes it's way to urine as well as albumin. - peripheral & facial edema (*preorbital* most notable in am) (ankles will swell when sitting, sacrum and scrotum when lying down) -waxy pallor skin -frothy foamy urine - hyperlipidemia - hypoalbuminemia - lipiduria - increased coagulation - reduced kidney function -poor appetite -hypertension *Treatment* -immunosuppressive agents - steroid -ACE inhibitors -heparin: clotting and renal percussion problems -diet changes: increase or decrease protein according to GFR(if normal GFR, need to increase protein to replace what is being lost in urine) -mild diuretics: lasix (if in fluid overload) -decrease protein: if kidneys aren't functioning -decrease Na+ unless GFR up then only moderate -decrease phosphorus -vitals, I/O -bed rest when SOB -adequate carbs for healing -monitor K+ -antihypertensives -statins: to lower triglycerides (to to get more cholesterol) -May have albumin IV to pull fluid back into the vessels -Diet: decrease protein, sodium and phosphorus if kidneys aren't functioning

*Urolithiasis (kidney stones) Medical and Surgical Management* Pg 1364

*extracorporeal shock-wave _lithotripsy (ESWL)_:* - patient is anesthetized (to ensure that he or she maintains the same position during the procedure. (conscious sedation) - a high-voltage spark generator produces high-energy acoustic shock waves that shatter the stone without damaging the surrounding tissues. - The stone is broken into fine sand (steinstrasse) and excreted in the urine. -Topical anesthetic cream is applied to site(skin) where stone will be removed 45 minutes prior to procedure. *-bruising may occur on the flank of the affected side.* *-should not be any bleeding* *She showed a video that was a different procedure not talked about in the book or her powerpoint* *electrohydraulic lithotripsy:* - the probe is positioned directly on a stone, but it breaks the stone into small fragments that are removed by forceps or suction. - A continuous saline irrigation flushes out the stone particles, and all of the outflow drainage is strained so that the particles can be analyzed. - The calculi can also be removed by basket extraction. *Nephrostomy* -Is an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects. Its job is to temporarily drain the urine that is blocked. May be done for stone that is blocking urine. *Nurse role* Assess for: -bleeding behind back - BIG CONCERN -amount of drainage (should not have any blood or urine in drainage from site) -infection -urine output -monitor for s/s of clogged tubing that is coming from site. (Decreases in output drainage and back pain). If potentially clogged, FIRST assess the clients abdomen and vitals, can use 5ml of sterile salients to dislodge clot, then call MD. Also notify MD for any signs of dehydration(hypotension, poor

*problems of urine outflow obstruction*

*hydronephrosis*: is the swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction. *hydroureter*: Abnormal enlargement of the ureter caused by any blockage that prevents urine from draining into the bladder. - nitrogen waste products and electrolytes are retained in the blood, and acid-base balance is impaired - causes: tumors, stones, trauma, structural defects, and fibrosis - early treatment prevents damage - damage can happen in as little as 48 hrs in some people and weeks in others Interventions include: -stone removal -stent placement -nephrostomy

*S&S of PKD*

- abdominal or flank pain is often first symptom - easily palpated cuz of increased size - flank pain as a dull ache or as sharp and intermittent discomfort -hypertension - when cyst ruptures, patient may have bright-red or cola-colored urine. - infection is suspected if urine is cloudy or foul smelling or if there is dysuria - nocturia (peeing at night) is an early sign is is because of decreased urine concentrating ability -increased abdominal girth -visceral pain - pain caused by the kidneys and other organs get displaced -constipation -bloody or cloudy urine -kidney stones -Infections to include UTI -sodium wassing and inability to concentrate urine in early stage -Headache (this was not in book or pp, but it seems to be a major symptom in everything I read) -cysts block renal perfusion which causes ischemia and pain worsens with activity

*Acute glomerulonephritis*

- an infection often occurs before the renal manifestations of acute GN - onset of symptoms is about 10 days from time of infection - usually recover quickly and completely - most causes are infectious or are related to other systemic diseases, MAINLY STREP!

*Education/preventing a UTI (chart 66-8 pg 1357)*

- drink at least 2-3 liters of fluid every day -Maintain I/O >30cc hour - be sure to get enough sleep, rest, and nutrition daily -if spermicides are used consider changing to another method of contraception. - women: clean your perineum (the area between your legs) from front to back - women: avoid using or wearing irritating substances, such as bubble bath, nylon underwear, and scented toilet tissue. wear loose-fitting cotton underwear - women: empty your bladder before and after intercourse - if you experience burning when you urinate, if you have to urinate frequently, or if you find it difficult to begin urinating, notify your physician or other health care provider right away, especially if you have a chronic medical condition (such as diabetes) or are pregnant - empty your bladder as soon as you feel the urge to urinate - empty your bladder regularly (q 4 hrs) even if you do not feel the urge to urinate (some NCLEX reviews state 2-3 hours) -burning or difficulty with flow starting, contact PCP - you may try these home therapies: cranberry juice (pure) 50 ml daily, apple cider vinegar 2 tbls three times daily in juice, vitamin c 500 mg daily to acidify urine - to prevent recurrent infection: take prescribed antibiotic or other drug as directed even after symptoms go away, schedule follow-up appointment for 10-14 days after you finish the drug. At your follow-up visit, another urine sample may be taken for analysis or culture. -don't wear wet bathing suits (mentioned in class) -limit caffeine intake (mentioned in class) -don't wear tight pants (mentioned in class) -Nurse needs to make sure to take urine culture before starting antibiotics or it will alter culture results. *-ACID ASH DIET ONLY with UTI*: makes urine more acidic. (produced by meat, poultry, cheese, fish, eggs, and grains)

*infectious causes of acute glomerulonephritis*

- group A beta-hemolytic streptococcus - staphylococcal or gram-negative bacteremia or sepsis - pneumococcal, mycoplasma, or klebsiella pneumonia - syphilis - visceral abscesses - infective endocarditis - hepatitis B - infectious mononucleosis - measles, mumps - rocky mountain spotted fever - cytomegalovirus infection - histoplasmosis - toxoplasmosis - varicella - chlamydia psittaci infection - coxsackievirus infection - any bacterial, parasitic, fungal, or viral infection (potentially)

*assessment of hydronephrosis and hydroureter*

- history of childhood UTI's - usual pattern of urination - recent flank or abdominal pain - inspect each flank for asymmetry and gently palpate to locate tenderness - urinalysis may show bacteria or white blood cells if infection is present

*types of cystitis*

- infectious: is the most common of the UTI's - noninfectious: caused by irritation from chemicals or radiation - interstitial: inflammatory disease that has no known cause -Acute uncomplicated UTI is usually cystitis or pyelonephritis in pre-menopausal women

*key features of renovascular disease*

- significant, difficult-to-control high blood pressure and increase in BP is sudden - elevated serum creatinine - decreased creatinine clearance *Diagnosis* *Interventions* -drugs that control high blood pressure -procedure to restore the renal blood supply: ballon angioplasty renal artery bypass

*staging renal tumors* Probably not on test

- stage 1. Tumors up to 2.5 cm are situated within the capsule of the kidney. The renal vein, perinephric fat, and adjacent lymph nodes have no tumor - stage 2. Tumors are larger than 2.5 cm and extend beyond the capsule but are within Gerota's fascia. The renal vein and lymph nodes are not involved - stage 3. Tumors extend into the renal vein, lymph nodes, or both - stage 4. Tumors include invasion of adjacent organs beyond Gerota's fascia or metastasize to distant tissues

*secondary glomerular diseases and syndromes*

- systemic lupus erythematosus - multiple myeloma - Schonlein-Henoch purpura - goodpasture's syndrome - systemic necrotizing vasculitis - Wegener's granulomatosis - periarteritis nodosa - amyloidosis - diabetic glomerulopathy - HIV-associated nephropathy - alport's syndrome - viral hepatitis B and C - cirrhosis - sickle-cell disease - nonstreptococcal postinfectious acute glomerulonephritis - infective endocarditis - hemolytic-uremic syndrome - thrombotic thrombocytopenic purpura

*lab assessment of acute glomerulonephritis*

- urinalysis shows RBCs and protein - early morning specimen preferred: urine is most acidic and formed elements intact - GFR: 90-100 normal. - BUN levels usually increased normal 7-21 - 24 hour urine collection for protein assay (often increases from 500 mg to 3 g) - serum albumin decreased - renal biopsy provides precise diagnosis and determines prognosis and treatment

*labs of PKD*

- urinalysis shows proteinuria once the glomeruli are involved - hematuria may be gross or microscopic - bacteria in urine indicate infection, usually in the cysts - as kidney function declines, serum creatinine and blood urea nitrogen (BUN) levels rise

*diagnostic assessment of chronic glomerulonephritis*

- urine output decreases but appears normal - urinalysis shows protein - specific gravity is at fixed level (1.010) - GFR is low. As kidneys loose function GFR goes down. Normal GFR is 90 -100 - creatinine and BUN is elevated - sodium retention common but may show false normal cuz of dilution - hyperkalemia - acidosis - kidneys small on x-ray - renal biopsy important in early stages, probably won't do in late stages cuz kidney will be so small -assess for uncontrolled hypertension -assess for edema

*caring for the patient undergoing hemodialysis* (chart 71-9)

- weight the patient before and after dialysis - know the patient's dry weight - discuss with the physician whether any of the patient's drugs should be withheld until after dialysis, otherwise they will be removed with dialysis. - be aware of events that occurred during the dialysis treatment - measure blood pressure, pulse rate, respirations, and temperature - assess for symptoms of orthostatic hypotension - assess the vascular access site - observe for bleeding, from site or any area of the body, ex. nose. administer protamine as antidote for heparin that is used during dialysis. - assess the pt's level of consciousness - asses for headache, nausea, and vomiting *NUTRITION for dialysis patient* • Eat more high protein foods. • Eat less high salt, high potassium, and high phosphorus foods. • Learn how much fluid you can safely drink (including coffee, tea, and water). • Use less salt and eat fewer salty foods: this may help to control blood pressure and reduce weight gains between dialysis sessions. • Use herbs, spices, and low-salt flavor enhancers in place of salt. • Avoid salt substitutes made with potassium. -People on dialysis need to eat more protein. Protein can help maintain blood protein levels and improve health. Eat a high protein food (meat, fish, poultry, fresh pork, or eggs) at every meal, or about 8-10 ounces of high protein foods everyday. -Unless you need to limit your calorie intake for weight loss and/or manage carbohydrate intake for blood sugar control, you may eat, as you desire from this food group. Grains, cereals, and breads are a good source of calories. Most people need 6 -11 servings from this group each day. -Limit your intake of milk, yogurt, and cheese to 1⁄2-cup milk or 1⁄2-cup yogurt or 1-ounce cheese per day. Most dairy foods are very high in phosphorus. The phosphorus content

*Prostate Cancer*

-2nd most common invasive cancer among men in the U.S. -African American population is highest risk and they get it at a younger age -One of the slowest growing malignancies; metastasizes in a predictable pattern -Accurate staging is needed for treatment planning and monitoring the course of the disease *First symptoms related to bladder neck obstruction Which are? Elevation in PSA and abnormal formation of prostate on rectal exam Bone pain? would indicate bone metastasis *Gross, painless hematuria is the most common presenting manifestation *Assessment* -Digital rectal examination -Prostate-specific antigen -Biopsy necessary to confirm suspected prostatic cancer -Several treatment options for prostate cancer -MRI: to look for bone involvement *Post op Care of Radical Prostatectomy* -Hydration with intravenous therapy -Caring for wound drains -Preventing emboli -Preventing pulmonary complications -Analgesics: Tylenol should be enough for pain -activity restriction 24 hours -prophylactic antibiotics -stool softener -indwelling urinary cath for up to 21 days -antispasmotic -No tub baths, dilates pelvic blood vessels -sex and exercise normally after 6 weeks *After biopsy* -mild pain 2 -3 days -discoloration of semen x 1 month -can run low grade fever no more than 99 -must pee within 8 hours, call MD if not -report high fevers, shakes, chills, bleeding more than 2 -3 day that continues to increase *complications* -urinary incontinence: teach kegal exercises -erectile dysfunction *these will improve unless prudenal is damaged

*Strategies a nurse uses with Urine Incontinence*

-Address underlying cause -Kegel exercises: Which muscles? If you can stop your urination flow mid-stream, you have identified your pelvic floor muscles. -bladder training: (patient needs good cognition) delay voiding according to a preschedule timetable. Take pt to the bathroom every 2 -3 hours no matter if they have to go or not. (chart 66-3 pg 1347) -Habit training: attempt voiding at specific time periods. Stretch the pt's length of time using the bathroom. If they have to go, push them 15 more minutes. -empty bladder every 3 -4 hours -containment of urine -nutrition -use of estrogen creme to strengthen pelvic floor muscles.

*Diagnostics for testicular cancer*

-Alpha-fetoprotein (Tumor markers) - glycoloprotein that is elevated during testicular cancer. -Beta subunit of hCG -Magnetic resonance imaging -Computed tomography -Ultrasound -Lymphangiograms

*Testicular Cancer*

-Although uncommon, this cancer is the most common malignancy in men 15 to 35 years of age. With early detection by testicular self-examination and treatment with combination chemotherapy, testicular cancer can be cured. -Testicular cancers fall into two major groups: Germ cell tumors arise from sperm-producing cells Seminomas: localized, metastasize late Non-seminomas: treated with surgery Non-germ cell tumors -very treatable if caught early -men can feel for small lumps. One of the first signs of the cancer Risk for Sexual Dysfunction: Common in Testicular Cancer -make sure patient donates sperm prior to any procedure

*Nursing Care during Peritoneal Dialysis*

-Before treating, evaluate baseline vital signs, weight, and laboratory tests. -Continually monitor the client for respiratory distress, pain, and discomfort. -Monitor prescribed dwell time and initiate outflow. -Observe the outflow amount and pattern of fluid. Bloody? Urine color? -Brown? indicates stool possible perforated colon -Cloudy? indicates infection #1 side effect -Any abdominal cramping, back or shoulder pain with decreased flow: slow down infusions this happens with new patients *NEVER microwave fluids, may be heated with heating pad or warm water*

*Renal Transplant*

-Candidate selection criteria: age <70 uncontrolled diabetes and hypertension polycystic disease -Donors -Preoperative care -Immunologic studies -HLA -Major barrier ? Long-standing pulmonary disease and chronic infection typically exclude clients from transplantation. These conditions worsen with the immune suppressants that are required to prevent rejection. Ex. TB -Operative procedure - placed in ileac breast Things to remember: -rejection major problem -uncontrolled diabetes and hypertension *Post Operative Care* Urologic management -Assessment of urine output hourly for 48 hours...why If urine output is low, need to assess BP for hypotension. If low, blood is not perfusing to new kidney. -Bladder irrigation... -Catheter removal... Complications include: -Rejection: Most common -Acute tubular necrosis -Thrombosis What would you see? -Renal artery stenosis What would you see? -Other complications -Immunosuppressive drug therapy For how long? Continual risk for? ***Patients frequently experience diuresis in the hours and days immediately following a kidney transplant.

*Post Cath Care*

-Client feels burning on urination as well as some urinary frequency, dribbling, and leakage. -Symptoms are normal and will subside. -Bleeding should decrease within 24 hours -Usually remove catheter after 24 hours -Monitor fluid intake. *If suspected clot: -stop bladder irrigation -look for bladder distention -look for kinks *When calculating fluid DO NOT USE IV fluid in calculation of input and output for bladder irrigation* WHY? aren't fluids still going to bladder and comes out? irrigation 200 cc hour x 4 hours IV 100 cc hour x 4 hours Foley 1200 cc Output =400 1200-800=400

*Diabetic Neuropathy*

-Diabetic nephrophathy is a microvascular complication of either type 1 or type 2 diabetes. -First manifestation is persistent albuminuria. -Avoid nephrotoxic agents and dehydration. -Assess need for insulin More or less? less insulin -causes sclerosis in glomerulus and vessels, which leads to decreased filtration. Lowered GFR (caused by dumping of albumin and sugar in) -Before using CT dye, assess GFR, BUN and Creatinine Once your nephrons are damaged you can't get new ones or regenerate the damaged ones. Most diabetics don't know they are getting destroyed until over 50% are destroyed and symptoms start.

*Benign Prostate Hyperplasia (BPH)* - cells reproduce Mass grows inside inward cells go up and cause hyperplasia

-Glandular units in the prostate that undergo an increase in the number of cells resulting in enlargement of the prostate gland -BPH grows inward, causing narrowing of the urethra *Bladder Involvement:* Hypertrophy -Hyper-irritable bladder urgency and frequency -Acute retention causes hydroureter, hydronephrosis, -Overflow urinary incontinence cause dribbling -Hypertrophy causes stasis and retention of urine. -Blood in urine *Assessment:* -Urinary pattern, frequency, nocturia, and other symptoms of bladder neck obstruction. Always feel like they need to go to the bathroom. -Lower urinary tract symptoms Hesitancy, intermittency, reduced force and size of urinary stream, a sensation of incomplete bladder emptying, and postvoid dribbling -Hematuria - one of the first signs BPH is the common cause of hematuria in men > 60 *Physical Assessment:* -Palpate bladder for enlargement -Digital rectal examination of the prostate -PSA of 4 or less is normal -Rule out cancer with PSA and digital exam -digital exam: should feel smooth and regular, stony and granular prostate indicates cancer *LAB assessment* -Urinalysis: With culture: rule out UTI -Complete blood count: looking for blood in urine -Blood urea nitrogen and creatinine levels: any kidney issues -Prostate-specific antigen Elevated in prostate cancer -KUB to detect flow rate and function *Interventions Medications* *-finasteride (Proscar) to shrink the prostate gland, and improve urinary flow, takes longer to work* -terazosin hydrochloride (Hytrin): BP med, increase flow through relaxation -doxazosin mesylate (Cardura): BP med increase flow through relaxation *-tamsulosin hydrochloride (Flomax)* Opens flow and relaxes vessels -Estrogens and androgens -Tolterodine (Detrol) - incontinence medication(Interventions the nurse suggests to alleviate the side effects of tol

*Erectile Dysfunction*

-Inability to achieve or maintain an erection for sexual intercourse Two classes of ED: -Organic erectile dysfunction Gradual deterioration of function Etiology? -Functional erectile dysfunction Psychological, stress related *assessment* -Medical, social, and sexual history - Organic or functional? -Complete physical examination -Duplex Doppler ultrasonography test *Detect blood flow to the penis *Nocturnal penile tumescence test *Interventions drug therapy* -Drug therapy includes sildenafil, vardenafil, tadalafil. Which are? Take it when? -Avoid alcohol before sexual intercourse. -Common side effects include headaches, facial flushing, diarrhea. -Men who take nitrates should not take these drugs in addition. *vacuum devices for ED* -Cylinder fits over the penis and sits firmly against the body. -Vacuum is created to draw blood into the penis to maintain an erection. -Rubber ring (tension band) is placed around the base of the penis to maintain the erection; cylinder is removed. *Don't forget to remove the ring!* *Intracorporal Injections* -Injecting the penis with vasodilating drugs - Into the side of the penis! -phentolamine and alprostadil -Adverse effects include: Priapism Penile scarring Fibrosis Bleeding Bruising Pain Infection Vasovagal responses Intraurethral Applications -Prostglandin E is a self-administered suppository that is placed in the urethra with an applicator. -Erection occurs in about 10 minutes and lasts 30 to 60 minutes. -Burning of the urethra occurs after application. *Penile implants are used when other modalities fail. *high risk of infection *Things to remember* -over 4 hour erection after using ED meds: go to ER -Demerol can be used to release erection -Warterm-115m enema or warm bath can help -large bore needle to pull off blood

*Urothelial Cancer*

-Malignant tundra of the urothelium (lining of the kidney, renal pelvis, bladder or uretha) -greatest risk factor - smoking -Normally painless, first sign blood in urine -Diagnosed by bladder wash specimen and biopsy *Risk of Bladder cancer caused from* -Smoking -Occupational hazard -Chronic UTI -Exposure to carcinogens -Diet *Clinical manifestations:* -Might have microscopic hematuria (You won't see it! You must test the urine for blood.) -Signs of urinary tract infection (frequency, urgency, dysuria) -Flank pain -Hydronephrosis of kidneys *STAGING* not likely to be on test _Stage 1_: Superficial and confined to the connective tissue and inner lining of bladder _Stage 2_: cancer has moved to muscle layer of bladder _Stage 3_: gone beyond muscle, moved to tissue _Stage 4_: In lymph nodes Stage I and II a bladder was is used with a live TB (adricomycin) virus to kill cancer. Also BCG a fluid to flush virus -Patient must use their own toilet and then use bleach to wash it. -Patient will have positive TB test -Increase fluids to flush out TB mix *PRE-OP* -Chemo - lowered immunity - infection precaution -Radiation - gi symptoms will follow as well as lower immune system and possibility of radiation burns. limit spicy or fatty foods, caffeine, and dairy products -Reduce size of tumor -IV *Stage III and IV* Bladder must be removed *Surgical Management* Fulgration ( A procedure that uses heat from an electric current to destroy abnormal tissue, such as a tumor or other lesion.) and Cystectomy (Cystectomy is a medical term for surgical removal of all or part of the urinary bladder) -Ileal conduit (illegal loop) stoma and pouch - constantly draining. Essentially a stoma for the urine. A bag is held outside the body -Neo Bladder: ouch inside where bladder was: connects to uretha. -Koch pouch: continent stoma that is not

*Chronic Renal Failure*

-Progressive, irreversible kidney injury; kidney function does not recover Pre-renal Post-renal *Risk Factors* -Hereditary & genetic factors: polycystic kidney disease -Infections: chronic pyelonephristis -Urinary tract obstructions: stones, Vesicoureteral reflux (VUR): is a condition in which urine flows backward from the bladder to one or both ureters and sometimes to the kidneys. ... Normally, urine flows down the urinary tract, from the kidneys, through the ureters, to the bladder. -Hypertension -Obesity, hypercholesterolemia -atherosclerosis -thrombus -diabetes: they need to keep A1C at a 7 or less -glomerulonephritis -smoking -other systemic diseases -drug induced: analgesics, gold, radiographic contrast, antibiotic -environmental risk factors: heavy metals *Stages* -Kidneys fail in organized fashion -gradual decrease in renal function -Clinical manifestations: 1.) Stage I: Diminished renal reserve creatinine clearance in 24 hour urine is down -best to treatment for this stage is to treat comorbid conditions -decreased urinary concentration(nocturia and polyuria) -observe and control BP 2.) Stage II: Renal insufficiency -BUN, serum creatinine, uric acid increases -K+ increased -decrease ability to concentrate urine -polyuria----> olyguria -GFR progressively decreasing -Clinical symptoms: headaches, edema, mild anemia, BP increased, weak and fatigued -be sure to manage glucose -ACE inhibitors are used to manage increased BP -educate on importance of DM control 3.) End Stage renal disease -excessive amounts of urea and creatinine in blood -kidneys cannot maintain homeostasis -dialysis *(see chart below for all symptoms from book in chronic)* *Chronic Renal Failure Changes* powerpoint • Kidney *Metabolic* -Urea and creatinine *Electrolytes* -Sodium - Potassium - Phosphorus - Magnesium - Calcium *Calcium

*Bladder Trauma*

-Stabbing and Gun shot wounds to the lower abdomen -Fractures should be stabilized before bladder repair, Bladder repair is sterile closed procedure and should be done last. -Pain below the level of the umbilicus that can radiate to the shoulders -always be aware of output, can lead to renal failure -trauma can lead to dehydration

*Peritoneal Dialysis - CAPD (continuous ambulatory peritoneal dialysis)*

-Surgically placed PD catheter -PD is done daily -Motivated patient: partner is not required -High risk of infection Aseptic technique is a must -Clean home environment -This type is much better at keeping fluid in body stable with toxin levels

*Continuous Bladder Irrigation:* Catheter Patency

-Three-way urinary catheter with a 30- to 45-mL retention balloon through the urethra into the bladder -Traction via taping to client's abdomen or thigh -Uncomfortable urge to void continuously -Antispasmodic medications *Things to remember* -30cc - 45cc balloon cath used and is taped snugly with resistance. Patient may complain, however it must be kept in place. -Nurse should assess ever 2 hours -If bag not draining: turn off first then check for kinks, have patient turn, then flush with 50cc in extra port to irrigate and clear potential clot. If this doesn't work, then call MD -Patient may complain about the urge to urinate, this is normal with the inflated balloon with pressure, however the nurse should assess that the tubing attached to the collection bag is patent. *IN CLASS SHE SAID:* -If bag is bloody: *turn up flow rate when -pinkish tinge -clots presents NCLEX exam challenge 72.2: A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is pink tinged and clear. What is the nurse's best action? A. Notify the charge nurse as soon as possible? B. Increase the rate of bladder irrigation ***C. Document the assessment in the medical record D. Prepare the patient for a blood transfusion *The book ALSO talks about:* Pg 1480-1481 -arterial bleeding: bright red blood(ketchup color) with clots. CALL MD immediately and irrigate. Medication likely to be prescribed to break up clot. -burgundy urine output: venous bleeding, notify surgeon

*Nutrition- Urinary Incontinence* pg 1366 table 66-5

-Weight loss: excess weight can cause stress incontinence -fluid intake: taking too much in. Drink during the day. Stop before bedtime. -Avoid coffee, alcohol, citrus based drinks (irritant) -Fiber and exercise: constipation can be an irritant

*assessment of acute glomerulonephritis*

-ask about history of infection - strep - inspect skin for lesions or recent incisions (including piercings) - assess the face, eyelides, hands, and other areas for edema (present in 75%) (preorbital) *BIG SYMPTOM* - assess for fluid overload and circulatory congestions (may accompany fluid and sodium retention) - ask about breathing difficulty or SOB - assess for lung crackles and S3 gallop heart tone(due to fluid overload), and neck vein distention - ask about urination changes. pts often describe urine as smoky, reddish brown, rusty, or cola colored - mild to moderate hypertension often occurs as result of sodium and fluid retention -anorexic -fatigue

*Urinary incontinence:* *Types of urinary incontinence* (pg 1345 table 66-1)

-defined as the involuntary leakage of urine -symptoms: -urgency: gotta go right now -frequency: voiding frequently -nocturia: needing to void at night; nocturia x 1 is common and normal -post-void dribbling-continued passage of urine after voluntary voiding has stopped *What is micturition* urination *Normal bladder volume:* -bladder volume > 250-350 mL -residual bladder volume after micturition <50 mL *What age-related changes happen to urinary physiology?* -decreased bladder capacity, ability to postpone urination, urine concentrating ability (increase in urine volume), bladder contractility-increase in post-void residual volume, sphincter resistance -increase in involuntary detrusor contractions *Types of Incontinence* *Stress* (small amounts during physical movements) urethra cannot be consciously tightened to overcome urination. Occurs during coughing, sneezing, jogging, or lifting *Urge* (leaking during unexpected times including sleep) urgent need to urinate due to bladder contractions regardless of the amount of urine in the bladder. AKA overactive bladder. Typically pass large amount of urine. Avoid anything that can irritate the bladder. ie. caffeine *Overflow* AKA reflex incontinence -*Impaired Detrusor* contractility and/or bladder outlet obstruction -Distended superpubic area (full bladder distended)(stroke and diabetic patient with poor muscle tone) -constant dribbling -detrusor muscle fails to contract and the bladder becomes over distended -urine must leak out of to prevent bladder rupture -post void residual -common manifestation of urethras stricture after urologic procedure. *Incomplete bladder emptying* -Never feels empty -weaken stream, dabbling, hesitancy -voiding, dysuria, nocturia -men with BPH prostate problems *Functional Deficit* instead of structural problem- result of factors

*Signs and Symptoms of UTI (chart 66-9 pg 1358)*

1) Frequency- have to void allot but not much coming out due to bladder and urethra is inflamed. 2) Urgency: sudden urge to urinate, due to involuntary contractions of the bladder muscle. 3) Dysuria - pain and burning when urinating 4) Odor in urine 5) Hematuria (microscopic or gross blood in urine) 6) Volume is not much when going 7)Pain/ pressure in suprapubic area when voiding (burning) Can have suprapubic pain 8) Cloudy urine (d/t pus, pH 4.6-8 normal --> phosphates can precipitate --> cloudy urine) 9) Incontinence: when you wet your drawers. 10 Nocturia: urinating through the night 11) Hematuria: blood in urine 12) Pyuria: is a condition that occurs when excess white blood cells, or pus, are present in the urine 13) Retention: is a condition in which your bladder doesn't empty completely even if it's full and you often feel like you really have to urinate 14) Feeling of incomplete bladder emptying 15) Hesitancy or difficulty in initiating stream 16) ****CONFUSION in elderly is first sign of UTI also not eating. Elderly also will have increased chills and be agitated* 17.) With Pyelonephritis the CVA will be tender. To assess you will want to place your hand on each side of angle, make a fist with other hand and tap the back. if pain, that kidney is infected. 18.) Spterm-7asms in bladder and kidney

*Contributing Factors to UTI (Table 66-3 pg 1355) others mentioned in class*

1. Obstruction 2. Stones (calculi) 3. Vesicoureteral reflux -backward flow of urine from the bladder into one or both ureters 4. Diabetes Mellitus -Diabetic Urine= alkaline Bacteria favors alkaline environment + DM affects immune system -->prone to UTI 5. Characteristics of urine: PH 6. Gender *women* -urethra is short -moist vulva -rectum is close to urethra *Men* - Catheterization - Urethral abnormalities - Unprotected vaginal/anal intercourse - Prostatitis - Lack of circumcision - BPH: obstruction 7. Age: As we age, we are more susceptible (1) women after menopause --> decreased glycogen in vagina --> affects the pH --> favor bacteria growth (women not taking or stopping hormone therapy (particularly estrogen, can increase the chances of a UTI) (2) interior vaginal wall - cystocele --> incomplete emptying (3) bowel incontinence - eccoli from bowel movement in close proximity to the opening of urethra (4) malnutrition & older adults 8. Sexual Activity -sexual activity can cause inflammation in urethra + bacteria can be transferred from anus to urethra during sexual activity... always irrigate and clean after intercourse. (makterm-9e sure you pee after intercourse) 9. Recent use of antibiotics 10. Urinary retention: bacteria and waste building 11. Medications: 12. Obstruction from pregnancy 13. Bacteria -bacteria from other infection can be transferred to kidney or bladder 14. Hygiene in women - Need to wipe: Front to back, not back to front(don't want to transfer E.Coli to the front)

*nephrotic syndrome*

A condition of increased glomerular permeability that allows larger protein molecules to pass through the membrane into the urine and then be excreted. -edema formation and decreased plasma albumin levels - most common cause is an immune or inflammatory process - can be result of genetic defect (Fabry dz) Normal urine protein is 0.15gm/day Proteinuria is >3.5gm/day (Too much protein in urine, proteinuria. Low levels of protein in blood (hypoalbumina) and high levels of fat and cholesterol in your blood.

*uremic frost*

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

*rapidly progressive glomerulonephritis*

A type of acute nephritis. Develops over several weeks or months and causes loss of kidney function. Patients become quite ill quickly and have manifestations of renal failure. - pt may have had previous infection or systemic disease, such as systemic lupus erythematosus - renal decline often progresses to ESKD - S&S: fluid volume excess, hypertension, oliguria, electrolyte imbalance, uremia

*treatment of nephrosclerosis*

Aims to control high blood pressure and reduce albuminuria to preserve kidney function. - ACE inhibitors - diuretics

*renal cell carcinoma*

Also known as adenocarcinoma of the kidney. Healthy tissue of the kidney is damaged and replaced by cancer cells. - systemic effects are called paraneoplastic syndromes and include: anemia, erythrocytosis, hypercalcemia, liver dysfunction with elevated liver enzymes, hormonal effects, increased sedimentation rate, and hypertension. - complications: metastasis and urinary tract obstructions - usually spreads to adrenal gland, liver, lungs, long bones, or other kidney

*polycystic kidney disease* Genetic disease

An inherited disorder in which fluid-filled cysts develop in the nephrons - cysts develop anywhere in the nephron, usually as a result of abnormal kidney cell division - over time cysts grow and become widely distributed - growing cysts damage glomerular and tubular membranes; nephron and kidney function become less effective - kidney tissue is eventually replaced by nonfunctioning cysts, which look like clusters of grapes - each cystic kidney may enlarge to 2-3 times its normal size, becoming as large as a football, can weight up to 10 lbs! - most of these pts have high blood pressure r/t renal ischemia from enlarging cysts - control of hypertension is top priority cuz proper treatment can disrupt the process that leads to further kidney damage -visceral pain that is acute or chronic PAIN is caused by enlargement of kidneys, which cause other organs to be misplaced. *Renal access is common in this dz.* s/s fever, flank pain, general malaise. tx with antibiotics and surgical incision to drain.

EVERYTHING BELOW HERE IS NOT ON MOD TEST

BUT COULD BE ON FINAL

*complications of hemodialysis*

Can occur with any type of access. - most common problems are thrombosis or stenosis, infection, aneurysm formation, ischemia, and heart failure - thrombosis, or clotting of the AV access, is the most frequent complication - most infections caused by staph aureus introduced during cannulation. Stay sterile. - aneurysms can form in the fistula and are caused by repeated needle punctures at same siteComplications: *Dialysis disequilibrium syndrome* -Due to rapid decrease in fluid volume -Monitor for complications such as hypotension, headache, nausea, malaise, vomiting, dizziness, and muscle cramps. Treatment? replace fluids or stop treatment -Infectious diseases -Hepatitis B and C infections -HIV exposure—poses some risk for clients undergoing dialysis

*chronic glomerulonephritis*

Develops over 20-30 years or even longer - exact onset rarely identified - cause often unknown but changes in kidney tissue result from hypertension, infections and inflammation, or poor blood flow to kidneys

*hydroureter*

Enlargement of the ureter. Obstruction is lower in the urinary tract - ureter dilation occurs above the obstruction and enlarges as urine collects

*interventions and post op care for RCC*

Focus on controlling the cancer and preventing metastasis - usually only effects one kidney *Nonsurgical Management* - radiofrequency ablation - chemotherapy: slow growing tumors *Surgical Managment* - radical nephrectomy with lymph node removal (can cause adrenal insufficiency so you need to watch patient closely) There will be an increase in urine output - adrenal gland left intact *Post Op* -monitor for adrenal insufficiency - large urine output followed by hypotension and then subsequent oliguria -assess Urine output -assess for infection -assess for bleeding (behind pt) flank incision -turn, cough, deep breathing Q 2hrs -semi fowler -If BP is decreased, pulse up, change in LOC, decreased urine output---> look for bleeding/hemorrhage. -give steroids

*interventions for acute glomerulonephritis*

Focus on managing infection, preventing complications, and providing appropriate patient education *Infection Management* -monitor temp -monitor I/O, weight and edema - appropriate antibiotic therapy - penicillin, erythromycin, or azithromycin - stress personal hygiene and handwashing *Complication Prevention* - diuretics and sodium and water restriction (yesterdays output + 500cc =restriction for today) - antihypertensive drugs - potassium and protein intake restricted - maintain restful environment -high calorie, low protein, low Na+, Low K+ (if GFR drops, reduce protein) (patient will have high K+) decrease carbonated drinks *Patient Education* - purpose and desired effects of drugs, dosage and schedule, side effects - dietary or fluid restrictions - measuring weight and BP at same time each day ~ May need dialysis or plasmapheresis -bed rest

*interventions for chronic glomerulonephritis*

Focus on slowing progression and preventing complications. -monitor temp -monitor htn -I/O weight edema -monitor for cites, pulmonary edema, CHF - crackles, S3 gallop in heart <----(call Dr. immediately indicates fluid overload secondary to failing kidneys) - diet changes - decrease Na+ - fluid intake -monitor for edema - drug therapy- monitor any nephrotoxic drugs - eventually, dialysis or transplantation -as kidneys lose function GFR goes down. WATCH`

*Home Dialysis*

HHD is done 6 days a week -Tx length is 2-3 hours/tx -Daily dialysis improves patient outcomes -Motivated patient and partner - willing to learn -AVF or AVG -Clean home environment- very important for to combat infection -Same care as for in-center HD patients

*urethritis*

Inflammation of the tube carrying urine from the bladder to the outside of the body. Inflammation of the urethra that causes symptoms similar to UTI. - symptoms similar to UTI in men or bacterial cystitis in women - most common cause in men is STDs. These include gonorrhea or nonspecific urethritis caused by urea-plasma, chlamydia, or trichomonas vaginalis - most men are asymptomatic - most common in postmenopausal women

*Interventions for testicular cancer*

Interventions include: - Surgical management Main tx for testicular cancer - Preoperative care - Operative procedures: radical retroperitoneal lymph node dissection, orchiectomy *POST OP* Postoperative care; expected problems include: -Pain from surgical incisions -Immobility -Injuries related to invasive catheters or tubes - Follow up with MD for incisional status, infection, tenderness, pain, no strenuous activities

*proteinuria*

Main feature of nephrotic syndrome is severe ___________.***

*renal replacement therapy*

Needed when the pathologic changes of stage 4 and 5 CKD are life threatening or pose continuing discomfort to the patient. - when he/she can no longer be managed with conservative therapies, such as diet, drugs, and fluid restriction, dialysis is indicated. - transplantation may be discussed at any time

*Complications*

Peritonitis -From what? Constipation (if constipated it won't drain well) -What will you see? decreased dialysis flow -What do you do? raise the bag -Pain (abdominal/shoulder): in new patients(slow the flow) -Exit site and tunnel infections: in new patients (slow the flow) -Poor dialysate flow -Dialysate leakage -Other complications - dark brown indicates stool

*nephrosclerosis*

Problem of thickening in the nephron blood vessels, resulting in narrowing of the vessel lumen. This change decreases renal blood flow, and kidney tissue is chronically hypoxic. Ischemia and fibrosis develop over time. - may be reversible if caused by hypertension - may lead to end stage kidney disease - rarely seen when BP is below 160/110 *Three main causes* 1.)occurs with all types of hypertension, 2.) atherosclerosis 3.)diabetes mellitus *Controlling BP is very important* *ACE is given to inhibit constriction*

*renovascular disease* (affects the renal arteries and causes sudden onset of hypertension

Processes affecting the renal arteries may severely narrow the lumen and greatly reduce blood flow to the kidney tissues. Same as coronary artery dz, just in kidney. - causes: *renal artery stenosis*, renal aneurysm, atherosclerosis, or thrombosis. So in other words, ischemia and atrophy to the renal tissue. - often have sudden onset of hypertension, particularly those older than 50

*RIFLE*

R - risk I - injury F - failure L - loss E - end stage kidney disease

*hemodialysis *

Renal replacement therapy is needed: -Physiologic changes of CRF are potentially life threatening -Or pose a continuing discomfort to the person -Client can no longer be managed with diet, drugs, or fluid restriction -Hemodialysis: -Remove excess fluids and waste products -Restores chemical and electrolyte balance -Passes blood through artificial semi-permeable membrane which filters and excretes toxins from the blood. Works by movement of wastes from a lower to higher concentration -Client selection -Dialysis settings -Blood is filtered through a semipermeable membrane to filter and excrete toxins -Works using passive transfer of toxins by diffusion -Blood and dialysate flow in opposite direction -Dialysate contains balanced electrolytes like human blood -Patients blood carries metabolic waste products -During HD the waste products move to the dialysate for excretion -What about patient's meds? Wait until after dialysis to give meds or they will go out during dialysis. -Anticoagulation needed, usually heparin to prevent blood clots. More susceptible to bruising and can bleed out. - most commonly, dialysis is started when uremic manifestations, such as n/v, decreased attention span, decreased cognition, worsening anemia, and pruritus, are present - may pts survive for years and other may live only a few months. Outcome depends on age, cause of kidney failure, presence of other diseases - pt selection: irreversible kidney failure (other tx ineffective), absence of illness that could complicate HD, expectation of rehabilitation, pt acceptance of regimen *DO NOT get teeth cleaned after dialysis. Risk for bleeding* - give heparin to prevent blood clots (antidote is protamine sulfate) If bleeding occurs anywhere, nose, site ect. administer protamine.

*Peritoneal Dialysis -through the abdomen*

Requirements for PD: through abdomen -Hemodynamically unstable -Can't tolerate anticoagulation -You DON'T need vascular access -Older client -Flexibility in scheduling -Less restriction of protein and fluids -Takes more time than HD Works by diffusion and osmosis -Across a semi-permeable membrane Membrane is large and porous -Solutes and water diffuse across from high concentration to low in the dialyzing fluid *Things to remember* -infection is the main concern: peritonitis (effluent(drainage) opaque cloudy color is first sign of peritonitis. -First couple of weeks after catheter insertion sterile dressing is used. After that soap and water is used -no alcohol use: dries cath -NO SCISSORS: tube getting cut could be bad! -drainage should be amber color with small amount of waste -no alcohol: dries out cath -drainage should be amber colored with small amount of waste *Things to watch when fluids aren't going in:* -if bag is not up high enough, won't flow. Works by gravity -constipation can also block fluid coming in: use stool softener and get patient moving around Peritoneal Dialysis involves: -Procedure involves siliconized rubber catheter placed into the abdominal cavity for infusion of dialysate. -The fluid dwells in the cavity for a specific time and then the waste products are drained Fill cavity-----> Dwell 1 - 2 hours-----> Drain

*reflux*

Reverse or upward flow of urine toward the renal pelvis and the kidney.

*Etiology and genetic risk of PKD*

Several forms & can be inherited as: *Autosomal Dominant PKD* - most common form - adult autosomal disorder - nearly 100% develop cysts by age 30 - 1/2 will develop chronic kidney disease (kidney failure) by age 50 *Autosomal Recessive PKD* - less common form - nephrons have cysts from birth - usually die in early childhood - caused by a gene mutation different from ADPKD

The formation of urine

Step 1 Renal artery - carries blood to the kidney Step 2 Renal Arteriole - blood flows Step 3 Glomerulus - filters water, salts, glucose, urea and small proteins - high pressure because fluid forced through capillaries of glomerulus OUT Step 4 Bowman's capsule - surrounds glomerulus Step 5 Proximal tubule - regulates the pH of the filtrate by exchanging hydrogen ion Resorption of 90% of filtrate -water( osmosis), Cl(passive transport) glucose, a.a and ions ( active transport) are taken back to the blood stream Step 6 Descending loop of henle - release water ( osmosis) Step 7 Ascending loop of henle - reabsorbs Na+ and Cl (salts- active transport) Step 8 Distal tubule - other ions and Na/K/ Cl ( active transport)reabsorbed and h20 by osmosis. And urea( diffusion) and drugs ( toxins) Step 9 Collecting ducts - urea and water balance PH of blood reabsorbed. Water leaves by osmosis. ADH promotes reabsorption of water form the collecting duct. When blood volume is low more h20 needed, adh promotes urine concentration Step 10 Ureter Step 11 Bladder Step 12 Urethra Step 13 Toilet *Important to remember* increase in ADH DECREASE urine volume increase in aldosterone DECREASE urine volume decrease in ANP DECREASE urine volume decrease in fluid intake DECREASE urine volume increase in other fluid output (sweating, vomiting, diarrhea, hemorrhage) DECREASE urine volume decrease in blood pressure DECREASE urine volume *Antidiuretic hormone (ADH)*: Vasopressin (drug form) The single most important effect of antidiuretic hormone is to conserve body water by reducing the loss of water in urine. *Regulates blood osmolarity (most important function) -Causes kidneys to reabsorb water into the blood, which decreases blood osmolarity *Regulates blood pressure (minor function) -Increases blood volume, which inc

*hydronephrosis*

The kidney enlarges as urine collects in the pelvis and kidney tissue. - because the capacity of the renal pelvis is normally 5-8 ml, obstruction quickly distends the renal pelvis. - kidney pressure increases as the volume of urine increases

*e-coli*

The most common pyelonephritis-causing organism is _-____.

*von hippel-lindau*

The most well-known genetic familial syndrome that includes renal cancer is ___ ______-______ syndrome. - these are highly vascular and may occur with cancers of the pancreas, CNS, and adrenal glands.

*glomerulonephritis*

Third leading cause of end-stage kidney disease (ESKD). Inflammation of the glomeruli. There is a genetic and immunologic component. - can be: acute- occurs after exposure to *STREP infection* about 2 -3 3 weeks later chronic-genetic; secondary to dz (lupus, diabetic neuropathy) it is steady and progressive -Primary Glomerular dz stems from glomerular injury. -Secondary Glomerular dz stems from underlying medical condition: lupus and diabetic neuropathy Many others listed below.

*How do the kidneys create urine?*

Via the nephrons in the kidneys (the heart also plays a role in this, specifically the blood flow given by the heart to supply the kidneys with blood). Each kidney contains millions of nephrons. Each nephron receives fresh blood from the heart via an afferent arteriole. The nephron consists of two main parts: Renal Corpuscle (function is to FILTER the blood and create filtrate..hence urine) Glomerulus Bowman 's capsule Renal Tubule (function is to REABSORB and SECRETE substances IN or OUT of the filtrate with the assistance of the peritubular capillaries) Proximal Convoluted Tubule Loop of Henle Distal Convoluted Tubule Collecting Tubule *In conclusion, there is the flow of substances back in forth from the nephron to the peritubular capillaries (circulation) until the filtrate is how the body wants it, and then it will leave the body as urine. Therefore, the tubules are crucial in deciding what should stay or go back into circulation. HOWEVER, when the nephrons are damaged as in INTRARENAL failure this mechanism is damaged and the patient will experience electrolyte imbalances, decreased glomerular filtration rate, decreased urinary output, azotemia (increase of BUN and creatinine in the blood...waste products). Urine consists of: Water Ions: sodium, chloride, calcium, potassium, magnesium, phosphate, bicarbonate Creatinine* Urea

*acute renal failure (aka acute kidney injury)*

What is Acute Kidney Injury? It is the SUDDEN/rapid decrease in renal function that will lead to the buildup of waste in the blood, fluid overload, and electrolyte imbalances. Develops rapidly- over hours to days AKI can be reversible. Basics about the kidneys: Role of the kidneys? Filters the blood which creates a filtrate called urine. In addition, the kidneys regulate electrolyte levels, removes waste, and excessive fluid in the body. The kidneys normally do NOT filter blood cells or proteins. An adult normally voids 1-2 liters of urine per day - causes: Pre-renal and Post Renal the kidneys have 3 responses: 1.) Constrict kidney vessels 2.) activate renin angiotensin 3.) leads to the release of ADH These responses lead to oliguria (low urine output below normal) <400 ml/day & Azotemia ((azot, "nitrogen" + -emia, "blood condition") is a medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood.) *Prerenal Injury:* issue with perfusion to the kidneys (any injury BEFORE the kidneys) C/O is down. This leads the kidney function to decrease. The kidneys are deprived of nutrients to function properly and the amount of blood it can filter. This can eventually lead to intrarenal damage where nephrons become damaged. What can lead to decreased perfusion to the kidney? Issues with the heart in conditions that decrease cardiac output as with an acute myocardial infarction. In this condition, the heart muscle is damaged and can't pump sufficient amounts of blood to the kidney. *ex myocardial infarction* *Other causes:* massive bleeding (internally or externally), dehydration (hypovolemia...diarrhea, vomiting), burns, CABGE etc. *Intrarenal Injury:* damage to the nephrons of th

*hypertension*

____________ is 2nd leading cause of end stage kidney disease.

*anuria* *oliguria*

anuria-Less than 100 ml/day of urine output oliguria-Less that 500ml/day of urine output

*uremia*

azotemia with clinical symptoms - causes severe itching -anorexia -nausea and vomiting -muscle cramps -edema

*azotemia*

high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood.

*cystitis (lower UTI)* Pg 1354

inflammation of the bladder. - caused by irritation or, more commonly, by infection from bacteria, viruses, fungi, or parasites.

*plasmapheresis*

removal and filtering of the plasma to eliminate antibodies

*uremic syndrome*

the systemic clinical and laboratory manifestations of end-stage kidney disease Uremia S/S -Anorexia -n/v -Muscle cramps -Itching -Edema -metallic taste -frosty skin -dyspnea -parastesia

*pyuria*

which blood cells in the urine