Patho II Exam 1

The most accurate measure of glomerular filtration

creatinine clearance

UTI signs & symptoms

dysuria frequency urgency suprapubic discomfort Urine may be cloudy or have visible blood present

Nephrotic Syndrome hallmark symptom

generalized edema

Glomerulonephritis

increased permeability of glomerulus effects both kidneys inflammation of glomerulus 3rd leading cause of renal failure

The selectively permeable glomerular capillary prevents what from leaving the blood?

large particles plasma proteins blood cells

What is considered an acidic pH of urine?

less than 6.0

5 factors that contribute to urine reflux

outflow obstruction catheterization vesicoureteral reflux pregnancy neurogenic bladder (r/t diabetes)

Extracellular fluid contains

plasma or serum

Intracellular fluid contains these minerals

potassium (high) magnesium (moderate) sodium (low) chloride bicarbonate phosphate calcium (almost none)

Blood levels represent over-all body levels EXCEPT for

potassium (much higher within cells than in serum)

S/S of Nephrotic Syndrome

proteinuria (>3.5g/dL) hypoalbuminemia (>3g/dL) hyperlipidemia generalized edema (because of decrease in serum albumin which balance fluids)

Is the glomerular capillary membrane permeable or impermeable?

selectively permeable

Manifestations of Pyelonephritis

shaking chills moderate to high fever constant loin ache (low back) lower UTI symptoms: dysuria, frequency, urgency N/V can be present Malaise (discomfort) Pt looks & feels ill

Oliguria

small urine production

Stagnant urine increases what to form in kidneys?

stones

Urosepsis

systemic infection that arises from a urologic source & can lead to septic shock

Primary glomerular disorder means:

the only disease present

Secondary glomerular disorder means:

the result of another disease (hypertension, diabetes)

microalbuminuria

used as a predictor of diabetic nephropathy

The selectively permeable glomerular capillary allows what to leave the blood and enter filtrate?

water small particles electrolytes glucose amino acids

A patient has had type 1 diabetes mellitus for 25 years and is now reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A. Serum creatinine B. Serum potassium C. Microalbuminuria D. Calculated glomerular filtration rate (GFR)

D. Calculated glomerular filtration rate (GFR) The best study to determine kidney function or chronic kidney disease (CKD) that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

Which urinalysis result should the nurse recognize as an abnormal finding? A. pH 6.0 B. Amber yellow color C. Specific gravity 1.025 D. White blood cells (WBCs) 9/hpf

D. White blood cells (WBCs) 9/hpf Normal WBC levels in urine are below 5/hpf, with levels exceeding this indicative of inflammation or urinary tract infection. A urine pH of 6.0 is average; amber yellow is normal coloration, and the reference ranges for specific gravity are 1.003 to 1.030.

What is the major cause of chronic kidney disease/failure?

Diabetic Nephropathy

Pre-renal failure blood flow is reduced because of

Diuretics Radiocontrast media Immunosuppressive drugs NSAIDs Aspirin

Most common UTI causing bacteria

E.coli others include: Enterococcus Klebsiella Enterobacter Proteus Pseydomonas Staphylococcus Serratia Candida albicans

CKD Stage 5

End-stage renal disease GFR <15 mL/min Need for dialysis

GFR

Glomerular filtration rate Best indicator of overall kidney function Varies w/age, sex, body size Normal GFR: 120-130 mL/min

Diuretic phase

Gradual increase in urine output but BUN & creatinine remain high Nephrons not working Tubules cannot concentrate urine (up to 5 L/day) Excessive loss of electrolytes & water Hypovolemia (decreased volume of circulating blood in the body) Hypotension

Stasis of urine predisposes patients to

Infections which can spread throughout the urinary tract

Intrinsic (Intrarenal) AKI

Injuries to structures within kidney Ischemia - major because Injury to tubular structures (necrosis) Intratubular obstructions Causes: Ischemia Sepsis, toxins Nephrotoxic drugs Amino glycosides (gentamicin Contrast agents Chemo drugs Tubular obstructions Can be reversed if treated promptly Seen in patients having: Major surgery Severe hypovolemia Blood transfusion reactions Overwhelming sepsis Trauma Burns

CKD Stage 3 & 4

Kidney damage GFR 15-59 mL/min for 3 months or longer Can occur in: Diabetics Hypertension Glomerulonephritis SLE Polycystic kidney disease

Prerenal AKI

Most common Decrease in renal blood flow Ischemia GFR drops Not enough ATP produced to keep nephron/tubular cells alive Causes: Impaired perfusion r/t MI, HF Drop in BP because fluid leaks from vessels into interstitial space. (Inflammation causes vascular permeability-fluid leaks out) Manifested by: Sharp decrease in urine output Increase in BUN (>20:1) Kidneys retain sodium to increase vascular volume

CKD Stage 2

No known kidney damage GFR 60-89 mL/min Can occur in infants & older adults (normal) Can occur with loss of one kidney, dehydration, HF, cirrhosis (liver damage)

Dull pain with obstruction

Non-colicky Flank area Pain increases with fluid intake Due to distention of collection duct & renal capsule

UTI signs & symptoms in older adult

None May only present with cognitive impairment

CKD Stage 1

Normal GFR Known kidney damage present

Normal BUN/serum creatinine

Normal: 12:1-20:1 Abnormal: >20:1

Postrenal AKI

Obstruction of urine outflow Ureter Bladder Urethra Causes: BPH (enlarged prostate) Diagnosis/treatment: Urine tests Inability to concentrate urine Serum tests: BUN creatinine Identify & correct cause Regulate fluids Adequate caloric intake/protein Prevent/treat infections Hemodialysis if needed

What type of urine output occurs with bilateral complete obstruction?

Oliguria Anuria

1/3rd of body fluid is found

Outside the cells Interstitial Blood vessels

Chronic Kidney Disease CKD

Permanent loss of nephrons/decline in function Causes: Diabetes Mellitis Hypertension Lupus s/s: edema (fluid overload) lung crackles anemia no erythropoietin *These patients end up on dialysis

What type of urine output occurs with bilateral partial obstruction?

Polyuria Nocturia

SLE - Systemic Lupus Erythematosus Glomerulonephritis (Lupus Nephritis)

Problem with regulation of B-cells which form autoantibodies toward a variety of cell membrane components Routinely screened for: Hematuria & Proteinuria

Manifestations of Chronic Kidney Disease

Proteinuria Fluid, electrolyte, acid/base balance disorders Problems w/calcium & phosphorous balance (bone diseases) Anemia-hematologic function Azotemia/Uremia (WASTE IN URINE) BUN Hypertension Nausea Vomiting Anorexia Hiccups GI bleeds

What does erythropoietin stimulate?

RBC production

Tubules

Reabsorb into the blood anything the body needs and secretes into the filtrate (urine) anything it doesn't need.

Oliguric phase

Reduction in urine output to <400 mL/day Urinalysis shows casts (cell masses) The longer the phase lasts the poorer the prognosis Decrease in GFR with retention of metabolites (urea, K, sulfate, creatinine) Urine output low Edema Hypertension Serum sodium decreases (dopamine used to inhibit sodium reabsorption-nephron workload decreases) Serum K increases Leukocytosis present-most common cause of death is infection

Acute/severe pain with obstruction

Renal colic Flank and upper outer quadrant Radiate to lower quadrant, bladder, scrotum, or perineum Skin is cool and clammy

Where will urine go if the outflow is blocked?

Renal pelvis & calyces causing dilation

Recovery phase

Repair of renal tissue Fall in serum creatinine & BUN

The nurse is caring for a 68-year-old man who had coronary artery bypass surgery 3 weeks ago. If the patient is now is in the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? A.Provide foods high in potassium. B.Restrict fluids based on urine output. C.Monitor output from peritoneal dialysis D.Offer high protein snacks between meals.

Restrict fluids based on urine output. Fluid intake is monitored during the oliguric phase. Fluid intake is determined by adding all losses for the previous 24 hours plus 600 mL. Potassium and protein intake may be limited in the oliguric phase to avoid hyperkalemia and elevated urea nitrogen. Hemodialysis, not peritoneal dialysis, is indicated in acute kidney injury if dialysis is needed.

Extracellular fluid contains these minerals

Sodium chloride (high) bicarbonate (moderate) potassium (low) magnesium calcium phosphate

Calculi (stones) nephrolithiasis

Super saturated urine (2 bound ions) Urine pH that binds ions Calcium Magnesium ammonium phosphate Uric acid Cystine

Where do immune complexes deposit in the kidney?

within the glomerular wall walls of interstitial vessels basement membrane of nephron

Diuretics

Thiazides: sodium & chloride exchange in the ascending loop of Henle Potassium (K) sparing: Inhibits reabsorption of sodium in the distal convoluted tubule Loop diuretics: inhibits exchange of Cl, Na, and K in the loop of Henle

What happens to the capillary membranes in someone with Diabetic Nephropathy?

Thickening of capillary walls leading to complete obliteration of lumens

What happens to the capillary membranes in someone with hypertension?

Thickens/narrows vessel walls decreased perfusion, atrophy, fibrosis

Acute Kidney Injury AKI

Tubular necrosis Occurs with: trauma shock sepsis medications Mortality rate of 60%

Lithotripsy

Use of sound waves to break up stones

Formation of crystals in tubules caused by

Vit C Sulfonamides (antibiotics) Chronic use of analgesics (painkillers) Illicit drug use

Glomerulus

Where filtration happens All electrolytes, waste, glucose is filtered out of the blood except proteins & blood cells

Immune complexes

antigens and antibodies bound together (IgG's clog the lumens)

Repetitive bacterial pyelonephritis can lead to

atrophy of cortex loss of tubular function inability to concentrate urine (polyuria, nocturia, mild proteinuria)

Glomerular disorder causes & triggers

*antibodies mixing with fixed glomerular antigens *circulating antigen-antibody complexes that become trapped in the glomerular membrane *can be autoantibodies i.e.: lupus (SLE) *can be exogenous: streptococcal antigens *often source of antibodies is unknown *diabetes (metabolic) *hypertension (hemodynamic) *toxic substances; drugs/chemicals

Nephrotic Syndrome can result in

*increase in glomerular permeability & loss of plasma proteins into urine *Salt & water retention (due to increased compensatory aldosterone) *Lipid increase leads to atherosclerosis *Protein loss leads to immune fx decreases *Loss of clotting factors (increases risk for DVT, PE)

Acute post streptococcal glomerulonephritis

*occurs following strep infections *staph *viral agents *deposition of immune complexes in glomerulus causes disease

Accumulation of immune complexes in the glomerular capillaries can cause

*oliguria *proteinuria & hematuria due to increased glomerular capillary wall permeability form inflammation *edema & fluid retention s/hypertension *cola-colored urine (blood!)

Positive and negative ions are called

+cations -anions

Dilute urine specific gravity

1.0006-1.010

Normal urine specific gravity

1.010-1.030

How many liters of urine do the kidneys filter/day?

1.5-2.0 liters/day

How many liters of blood do the kidneys filter/min?

120-130mL/min (this is the GFR)

1 liter of water weighs___________pounds

2.2

Benign prostatic hyperplasia

A condition in men in which the prostate gland is enlarged and not cancerous

Nephrotic Syndrome

A kidney disorder that causes the body to excrete too much protein in the urine (macroproteinuria & massive edema)

Albumin

A protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid portion of the blood. Albumin can also be measured in the urine

In addition to urine function, the nurse recognizes that the kidneys perform numerous other functions important to the maintenance of homeostasis. Which physiologic processes are performed by the kidneys? Select all that apply. A. Production of renin B. Activation of vitamin D C. Carbohydrate metabolism D. Erythropoietin production E. Hemolysis of old red blood cells (RBCs)

A, B, D. In addition to urine formation, the kidneys release renin to maintain blood pressure, activate vitamin D to maintain calcium levels, and produce erythropoietin to stimulate RBC production. Carbohydrate metabolism and hemolysis of old RBCs are not physiologic functions that are performed by the kidneys.

The nurse knows the patient with AKI has entered the diuretic phase when what assessments occur? Select all that apply. A. Dehydration B. Hypokalemia C. Hypernatremia D. BUN increases E. Serum creatinine increases

A, B. Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Therefore the serum BUN and serum creatinine levels also begin to decrease.

A client has developed acute renal failure (ARF) as a complication of glomerulonephritis. The nurse assesses the client for which of the following as an expected manifestation of ARF? A. Hypertension B. Bradycardia. C. Decreased cardiac output D. Decreased central venous pressure

A. ARF caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of ARF is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. ARF from prerenal causes is characterized by decreased blood pressure, or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for any form of renal failure.

The patient has a form of glomerular inflammation that is progressing rapidly. She is gaining weight, and the urine output is steadily declining. What is the priority nursing intervention? A. Monitor the patient's cardiac status. B. Teach the patient about hand washing. C. Obtain a serum specimen for electrolytes. D. Increase direct observation of the patient.

A. Monitor the patient's cardiac status. The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider.

Collecting Duct (tubule)

ADH impacts here Water only! Increase in ADH leads to increased reabsorption Decrease in ADH leads to increased secretion

A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? a. Obtain renal ultrasound. b. Insert retention catheter. c. Infuse normal saline at 50 mL/hour. d. Draw blood for complete blood count.

ANS: B The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter

A client in renal failure is to have a serum blood urea nitrogen level determined. What will this diagnostic test measure? A. Concentration of urine osmolarity and electrolytes B. Serum level of the end products of protein C. Ability of kidneys to concentrate urine D. Levels of C-reactive protein to determine inflammation

ANS: B Urea is an end product of protein metabolism. In renal failure, the kidneys cannot clear all of the urea from the blood, and the creatinine and BUN level will be elevated. The C-reactive protein is a diagnostic test used in assessing clients with inflammatory bowel disease, rheumatoid arthritis, autoimmune diseases, and PID. A specific gravity test of the urine would assess the ability of the kidneys to concentrate urine. The urine osmolarity (concentration of particles in urine) and electrolytes assess fluid balance. The kidneys play an important role in the balance of electrolytes and fluids.

Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)? A. Blood urea nitrogen (BUN) level B. Urine output C. Creatinine level D. Calculated glomerular filtration rate (GFR)

ANS: D GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function.

Pyelonephritis

Acute bacterial infection of renal pelvis due to reflux of urine & a UTI (escherichia coli, klebsiella, enterobacter, pseudomanas)

Factors effecting nephropathies

Age (elderly highly susceptible) Hydration BP pH of urine

Azotemia

An elevation of BUN and serum creatinine levels

Intravenous pyelography

An x-ray examination of the kidneys, ureters and urinary bladder that uses iodinated contrast material injected into veins

Which assessment finding is a consequence of the oliguric phase of AKI? A. Hypovolemia B. Hyperkalemia C. Hypernatremia D. Thrombocytopenia

B. Hyperkalemia In AKI the serum potassium levels increase because the normal ability of the kidneys to excrete potassium is impaired. Sodium levels are typically normal or diminished, whereas fluid volume is normally increased because of decreased urine output. Thrombocytopenia is not a consequence of AKI, although altered platelet function may occur in AKI.

The nurse is reviewing the client's record and notes that the physician has documented that the client has a renal disorder. On review of the lab results, the nurse most likely would expect to note which of the following? A. Decreased hemoglobin level. B. Elevated BUN C. Decreased red blood cell count. D. Decreased white blood cell count.

B. Measuring the blood urea nitrogen level is a frequently used laboratory test to determine renal function. The blood urea nitrogen level starts to rise when the glomerular filtration rate falls below 40% to 60%. A decreased hemoglobin level and red blood cell count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased white blood cell count is most likely to be noted in renal disease.

A client is admitted to the hospital with a diagnosis of early-stage chronic renal failure. Which of the following should the nurse expect to note on client assessment? A. Anuria. B. Polyuria. C. Oliguria. D. Polydypsia.

B. Polyuria occurs early in chronic renal failure and, if untreated, can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal kidney functions. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal failure.

Uremia

BUN creatinine elevated Muscular irritability Seizures Somnolence Coma Death

Where will urine continue to cause damage the further it goes?

Back up the collecting duct/tubules causing damage and atrophy (leads to inability to concentrate urine) GFR is impacted

What factors may have caused a UTI?

Bacteria ascending up urethra from: GI tract Bladder instrumentation sex obstruction catheter acquired (most common nosocomial UTI)

Renin-angiotensin function regulates what 3 things?

Blood pressure Blood volume Release of erythropoietin

Kidney failure occurs when kidneys fail to remove what from the blood and fail to do what with extracellular fluids?

Blood: removal of metabolic end products Fluids: fluid regulation, electrolytes, pH

The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of: A. Pyelonephritits B. Glomerulonephritis C. Trauma to the bladder or abdomen D. Renal cancer in the client's family

C. Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather pain would be in the flank area.

2/3rds of body fluid is contained within

Cells (intracellular)

Obstructive Disorders can be caused by

Congenital anomalies Calculi (stones-most common) Pregnancy BPH Scar tissue (infections/inflammation) Neurologic (spinal cord injuries)