NURS 315 Chapter 50 Exam 1

What is glomerular filtration rate (GFR) and its normal range? Which diagnostic test can be used to measure GFR?

- Glomerular Filtration Rate: The amount of blood filtered by the glomeruli in a given time. Most reliable indicator of kidney function

- Normal Range: 70-135ml/min (125 mL/min)

- GFR can be lower in older adults

- Diagnostic Test Used to measure GFR: 24-hour urine collection, based on creatinine levels

Bicarbonate normal range and changes when kidney function is impaired

Normal Range: 22-26 mEq/L

Changes: Most patients in renal failure have metabolic acidosis and low serum HCO3 − levels.

BUN normal range and changes when kidney function is impaired

Normal Range: 10-20 mg/dL

Changes: Nonrenal factors may ↑ BUN

BUN/Creatinine normal range and changes when kidney function is impaired

Normal Range: 12:1-20:1

Changes: Increased ratio may be due to conditions that ↓ blood flow to kidneys

Calcium normal range and changes when kidney function is impaired

Normal Range: 9.0-10.5mg/dL

Changes: Lower

Creatinine normal range and changes when kidney function is impaired

Normal: Males 0.6-1.2mg/dL/Females 0.5-1.1mg/dL

Changes:

Potassium normal range and changes when kidney function is impaired

Normal Range: 3.5-5.0 mEq/L

Changes: High K+ levels >6 mEq/L can lead to muscle weakness and dysrhythmias.

Sodium normal range and changes when kidney function is impaired

Normal Range: 136-145mEq/L

Changes: Lowers

Phosphate normal range and changes when kidney function is impaired

Normal Range: 3-4.5

Changes: Higher because of indirect relationship with calcium

What are the normal findings in urinalysis? (casts, proteinuria, oliguria, anuria, fixed gravity)

- Casts: None

- Protein: Random protein: 0-trace / 24h protein: 50-80mg/day

- Specific gravity: 1.005-1.030

Oliguria: Having very little urine output

Anuria: Having no urine output

Who are at the risk of development of urinary tract infection (UTI)?

Hospitalized individuals with catheters, females - specifically those going through menopause, pregnant women, people with suppressed immune systems, Age (older adults), dehydration/malnutrition

Pyelonephritis

Upper tract; kidney, implies inflammation (usually caused by an infection) of the renal parenchyma and collecting system

Cystitis

Lower tract; inflammation of the bladder

Urethritis

Lower tract; inflammation of the urethra

Upper Tract symptoms

fever, chills, and flank pain

Lower Tract symptoms

Dysuria, frequency (voiding more than every 2 hours), urgency, and suprapubic discomfort or pressure. The urine may have grossly visible blood (hematuria) or sediment, giving it a cloudy appearance

What are the characteristics of UTI symptoms among older patients?

- Asymptomatic - typically mental status changes

How would you instruct patients when they take antibiotics and over-the-counter medicines for UTIs?

- Take full course of antibiotics - even if symptoms are gone continue to take it

- Use over the counter (OTC) to relieve discomfort - Pyridium (inform patient that urine color may be orange), Urised (inform patient that urine color may be greenish/blueish)

How would you promote the prevention of UTI in community and hospital settings?

ADD

How would you teaching patient about preventing UTIs?

1. Take all antibiotics as prescribed. Symptoms may improve after 1-2 days of therapy, but organisms may still be present.

2. Practice appropriate hygiene, including:

• Carefully clean the perineal region by separating the labia in females, or in males pulling back the foreskin if present when cleansing.

• Wipe from front to back after urinating.

• Cleanse with warm soapy water after each bowel movement.

3. Empty the bladder before and after sexual intercourse.

4. Void regularly, about every 3-4 hours during the day.

5. Maintain adequate fluid intake.

6. Avoid vaginal douches and harsh soaps, bubble baths, powders, and sprays in the perineal area.

7. Report to the HCP symptoms or signs of recurrent UTI (e.g., fever, cloudy urine, pain on urination, urgency, frequency).

Glomerulonephritis

Immunologic processes result in inflammation of the glomeruli. NOT an infection. Bowman's capsule doesn't work

What medical history will help you to identify the risk of glomerulonephritis?

Recent respiratory or throat infection

What are the clinical manifestations of glomerulonephritis?

Hematuria, proteinuria, periorbital and peripheral edema, hypertension, flank pain

How to modify fluid intake, diet, and activity level for patient with APSGN?

- Fluid intake: restrict sodium and fluid intake, diuretics

- Diet: Low protein diet, kidney is unable to filter it out - can give antihypertensive medications and antibiotics if strep infection is still indicated

- Activity Level: REST, allow kidneys and immune system to take a break

Nephrotic Syndrome

Glomerulus is excessively permeable to plasma protein - lots of protein is lost

What are the clinical manifestations for nephrotic syndrome?

Severe proteinuria (>3.5g/day), Hypoalbuminemia (normal is 3.5-5), Peripheral edema, hypo-/hypertension, hyperlipidemia (liver produces more protein which also produces more cholesterol, more than 200), infections, hypercoagulation

How would you modify patient's fluid intake and diet to treat the symptoms of nephrotic syndrome?

- Fluid Intake: Low sodium, diuretics

- Diet: Moderate/increase protein diet

How would you monitor for edema for renal patients?

- Daily weight, I and O, abdominal girth

- If treatment for nephrotic syndrome is working, edema should be better with these monitoring techniques

What are the major risk factors for the development of Urinary Tract Calculi?

Climate

• Warm climates that cause increased fluid loss, low urine volume, and increased urine solute concentration

Diet

• Excess amounts of tea or fruit juices that increase urinary oxalate level

• Large intake of diet proteins that increases uric acid excretion

• Large intake of salt, low calcium intake

• Low fluid intake that increases urine concentration

Genetic Factors

• Family history of stone formation, cystinuria, gout, or renal acidosis

Lifestyle

• Immobility

• Obesity

• Sedentary occupation

Metabolic

• Abnormalities that result in increased urine pH, calcium, oxalate, or uric acid levels, or low citrate

Calcium Oxalate stone treatment

Increase hydration. Reduce oxalate intake (spinach, beets, potatoes, leafy greens, almonds, cereal grains), animal protein, and sodium. Increase intake of calcium, fruits, and vegetables. Give thiazide diuretics. Give potassium citrate to maintain alkaline urine. Avoid vitamin C and calcium supplements.

Uric Acid stone treatment

Increase hydration. Reduce urinary concentration of uric acid. Alkalinize urine with potassium citrate. Consider allopurinol. Reduce purine intake (meats and seafood)

What are the major clinical symptoms and their complications for Urinary Tract Calculi?

- Manifestations: severe abdominal or flank pain, hematuria, fever

- Complications: UTI (infection), Acute urinary retention

What are the major interventions and nursing care principles for Urinary Tract Calculi?

- Noncontrast CT/KUB

- Intravenous pyelogram (IVP)

- Pain control (PRIORITY) - opioids

- Monitor urinary elimination

- Control infection

Intravenous pyelogram (IVP)

NPO, check iodine and shellfish allergy and assess kidney function first, normal reaction to dye - flushed face, salty taste

Post cystoscopy

-Used for stones in the bladder

o Cystoscope is interested into the bladder and crushes the stone

§ Complications:

· Expect burning, pink tinges (not red!) urine, and frequency

· May need continuous bladder irrigation to prevent clots

What complications do you need to watch for during post-op period?

- Complications: bleeding, injury, and infection

What post op teaching do you give?

- Strain urine through gauze to collect stone

o Identifies the type of stones to help educate patient on dietary restrictions and treatment plan in the future. Encourage fluid (3L/day) and encourage ambulation

What are the major clinical manifestations of PKD?

- Enlarged kidney, hypertension, hematuria, pain, multisystem involvement

What educational information would you provide to a patient who has been diagnosed as Polycystic kidney disease (PKD)?

- Educate patient to have their children come to the hospital to have the counseling and screening for PKD because it is a genetic condition

- Also educate about pain management and monitor for hypertension/bleeding/pain/infection and other clinical manifestations

- Educate about avoiding activities that can cause a risk for injury to then kidney (prevent rupture)

What are the risk factors for bladder cancer?

Males, most common at age 60-70, smoking, Exposure to: dyes, rubber, leather, ink, paint, chronic renal calculi, UTI

What are the characteristics of the symptoms for bladder cancer?

Painless gross hematuria (blood is easily seen), dysuria, freq, urgency

Intravesical Therapy

- BCG is placed in the bladder for 1-2 hours acting as chemotherapy or immunotherapy for bladder cancer

o First, the patient must void, then a catheter is placed, and the medication is inserted into the bladder

o The patient must change position every 15 minutes, so the medication is washed over each part of the bladder

o This therapy is done once a week for 6-12 weeks

o Patient may develop flu like symptoms

Urinary Incontinence Treatment (functional, overflow, reflex, stress, urge)

- Functional incontinence: Modifying environment

- Overflow: straight cath

- Reflex: Treat underlying cause, pelvic floor exercises, anticholinergics

- Stress: Kegal exercises

- Urge: Ditropan (anticholinergic), bladder training

What is your first action when you identify patient has acute urinary retention?

Catheter insertion

Indwelling Catheter Uses

o Relieve urinary retention caused by lower urinary tract obstruction, paralysis, or inability to void

o Bladder decompression preoperatively and operatively for lower abdominal or pelvic surgery

o Facilitate surgical repair of urethra and surrounding structures

o Splinting of ureters or urethra to promote healing after surgery or other trauma in area

o Accurate measurement of urine output

o Contamination of stage III or IV pressure injuries with urine that has impeded healing, despite appropriate personal care for the incontinence

o Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain

Incontinent Urinary Diversion

Ileal conduit

o Ureters implanted into part of ileum or colon that has been resected from GI tract. Abdominal stoma is created.

Continent Urinary Diversion

Kock pouch, Indiana pound

o Part of the bowel is made into a pouch in which the urine drains into

Orthotopic Bladder Reconstruction

Neobladder

o Fake bladder made out of bowels and attaches to ureters

o Patient is able to urinate out of their urethra

Ileal Conduit

- Requires patient to wear appliance over the stoma to collect urine. Teach how to change bag, how to control odors (a little bit of vinegar), how to take care of the skin around the stoma,

o After the surgery: Patency of the ileal conduit - monitor urine output and color of stoma

Kock pouch and Indiana pouch

patient needs to self-catheterize the stoma to drain the reservoir at 4- to 6- hour intervals

Neobladder

patient empties the neobladder by relaxing the external sphincter and bearing down or by intermittent self-catheterization because they have no desire to void

Pre-op and Post-op care for urinary diversion

- Pre-op: assess readiness to learn

- Post-op:

o Prevent surgical complications

o Prevent injury to stoma (stoma should be pink or red), instruct altered elimination pattern, skin care, maintain urine output by high fluid intake

o Address physiological needs: body image

o Discharge instruction: symptoms of infection and obstruction, care of ostomy (secretions around is normal, odor, crust around stoma), appliances

o Never clamp tubing, always make sure the catheter is not obstructed or kinked

Main points in pt teaching on self-care of urostomy bag

1. Keep pouch in place for 3-4 days. May need changed more or less often as needed.

2. Change pouch when fluid intake has been restricted for several hours.

3. Sit or stand in front of mirror.

4. Can moisten edge of faceplate with warm water or adhesive solvent and gently remove.

5. Use warm water and a washcloth to clear the skin around the stoma. Use soap to remove any adhesive solvent.

6. Dry skin and inspect.

7. Place wick (rolled-up 4 × 4-inch pad) over stoma to keep skin free of urine.

8. Place pouch over stoma.