medsurg renal

Renal failure whether acute or chronic...

is a life-threatening condition

the ability of the body to maintain its internal environment at a "steady state" within very narrow ranges of normal regardless of external changes

homeostasis

store urine made by the kidney & eliminate it from the body

ureters, bladder, urethra

volume of urine in kidney pelvis triggers stretch receptors to increase ureteral smooth muscle contractions & move urine from kidney pelvis to bladder by peristalsis

movement of urine

Stores urine, provides continence, and enables micturition; a muscular sac (for women it is in front of the vagina)

bladder

where are control centers for voiding located; injury to these areas may result in involuntarily loss of bladder control & emptying

cerebral cortex, brainstem, lower spinal cord

serves to eliminate urine from the bladder

urethra

what is the anatomy of the urethra in men

6-8 in long (extends from bladder through prostate gland, then from prostate to wall of pelvic floor)

What is the anatomy of the urethra in women

1-1 1/2 in long (slightly below clitoris & directly in front of vagina & rectum)

maintain body fluid volume & composition; filter waste for elimination; help regulate BP; help regulate acid-base balance; produce erythropoietin for RBC synthesis; convert vit D to active form; perform the actual work of determining which substances in body fluid will be eliminated

Kidney functions

How much blood does the kidney receive

~ 600 to 1300 mL blood/min (20-25% of CO)

Reduced blood flow to kidneys (~10% per decade) causes kidneys to get smaller
decreasing ability to filter blood & excrete waste products
# of glomeruli decreases which decreases GFR

Changes associated with aging

Decreased blood flow, decreased kidney mass and decreased GFR leads to

decreased drug clearance, increased risk for drug reaction, nephrotoxicites & damage from drugs & contrast dyes

What leads to urgency

decreased bladder capacity and decreased ability to concentrate urine

In women decreased sphincter & detrusor muscles can lead to

incontinence

In women, shorter urethra

increase risk for UTI

In men, enlarged prostate gland..

makes starting urine stream difficult and may cause retention

Chronic health problems (i.e., HTN, DM)..

increase risk for development of kidney disease r/t kidney blood vessel damage

What question should you use to determine if the pt has HTN?

have you ever been told your blood pressure is high?

What can be associated with compromised kidney function

dietary supplementation (i.e. synthetic creatine, weight loss)

What can reduce kidney function

High-dose or long-term use of NSAIDs or acetaminophen

What is normal UOP for adults?

1500-2000mL/day or within 500 mL of volume of fluid ingested daily

auscultate before percussion & palpation (can enhance bowel but mask abdominal vascular sounds)
BE CAREFUL WITH DEEP PALPATION
leave palpation of kidneys/CVA assessment to adv. practioner;
gently palpate & percuss bladder or use scanner if retention suspected
may encounter cultural, privacy, embarrassment issues

proper renal assessment methods

Cr levels

0.5-1.2 mg

product of muscle & protein decomposition
"no common pathologic condition other than kidney disease increases the serum ___________ level; at least 50% of kidney function must be lost before you see the increased level

Creatinine

blood urea nitrogen (BUN) level

10-20

measures effectiveness of kidneys to excrete urea nitrogen (protein decomp waste product); _________ can be increased by other factors so not necessarily best indicator of kidney function but is a tool for assessing kidney dysfunction

blood urea nitrogen (BUN)

what should urine specimens be free from

toilet tissue, fecal contamination, menstrual blood

IDs the organism (i.e., candida, staphylococcus, Escherichia coli); guides to which antibiotic is effective

urinalysis (UA) may need to test further with C&S

The more concentrated morning 1st void is best; if clean catch, give good instructions to prevent contamination; do not delay delivery to lab; cover & refrigerate if delay in delivery

Proper method for UA collection

All urine within designated time frame must be collected, give pt/family/caretakers explicit instructions; use conspicuous signage as reminder; lab will instruct on need for special preservatives, ice or no ice

Timed urine collection (i.e., 24-hour urine)

Pt voids, discard this 1st void, note the time; if foley cath: empty tubing & drainage bag, discard, not the time; ensure all urine formed within the 24-hr period s collect, at the 24-hr mark, have pt void and include that urine in collection (do not remove urine from collection container for other specimens)

24 hour urine lab process

Provider is responsible for explaining the procedure to the patient, RN may need to ensure completion of signature on informed consent

any procedure requiring informed consent

Pre-op checklist
any prep order (i.e., edema, laxative, bowel prep)
NPO or diet orders

what the RN is responsible for

Common diagnostic imaging for renal

KUB (kidneys, ureter, bladder); CT (may be with or without contrast)

What should you check with for CT

Check allergies, asthma, renal function, metformin; ensure hydration for dye dilution and excretion

Cystoscopy

cystoscope through urethra into bladder

May have pink tinged urine but not grossly red, may have orders to irrigate foley catheter if clots expected

Cystoscopy addi. info

instill dye into area via catheter; take x-rays as dye is excreted to look for flow abnormalities or obstruction

retrograde pyelo/cysto/urethro- gram

there is a risk for bleeding: check coagulation, site, VS, s/sx of internal bleed

kidney biopsy: percutaneously

often hear terms used for both infectious process & inflammatory process which may not be infectious

urinary tract infection

UTIs: most common health care-associated infection due to.....

Catheters not draining to gravity, reflux of urine, inadequate hygiene

Lower UTI

urethritis, cystitis, prostatitis

Upper UTI

Acute pyelonephritis

Spread of infection from urinary tract to bloodstream

urosepsis

presence of WBCs in urine

pyuria

Presence of RBCs in urine

Hematuria

presence of bacteria in urine

bacteriuria

ability to invade & infect

virulence

UTI - what can cause it (7)

Incomplete bladder emptying, obstruction (stones, BPH), DM/uncontrolled glucose, antibiotic use, sexual activity, immunosuppression, irritants (douches, powders, perfume)

Organisms from the external urethra ascend the urinary tract, infection spread through the blood & lymph, and irritation/trauma/ instrumentation of linings/mucosa
Bacteria finds a susceptible place along the urinary tract to colonize, then multiply, surmounting our normal host protective flora resistance

UTI what's going on

Urgency, dysuria, frequency, difficulty starting urine stream, low back pain/flank pain, nocturia, incontinence, hematuria/blood-tinged, pyruia

UTI what does it look like

confusion, falls, incontinence or change in continence, tachycardia, fever, tachypnea, hypotension, slight rise in temperature

older adult UTI hallmark symptoms

hallmark symptoms of UTI in younger clients

fever, dysuria, and urgency

Nitrofurantoin (macrodantin): bacteriostatic
Trimethoprim (TMP)/ sulfamethoxazole (Bactrim, septra): bactericidal/bacteriostatic

uncomplicated UTI 1st line drug therapy choices

Fungal (candida) UTI drug of choice (DOC)

fluconazole

Other UTI drugs...

may also be prescribed analgesic (i.e., pyridium) &/or antispasmodic (i.e., hyoscyamine.)

Ensure appropriate use of indwelling urinary catheters
Sterile/aseptic/clean technique during urinary catheter insertion
Discontinue catheter use at earliest time frame
Sufficient fluid intake when not contraindicated
Proper hygiene
Healthy urinary elimination patterns
Knowledge of meds & med adherence
Discussions of sexual intercourse

UTI pt teaching

What is lithiasis

the formation of stones
(uro: urinary tract, nephro: kidney, uretero: ureter)

Possibly explained by excess crystalization
Imbalance of urine pH
Calcium complexes
Genetic implications, family history
Previous incidences of stone formation
Gout

What can cause lithiasis?

Excessive amounts of stone composing element
Absorbed through intestinal tract
Blood circulates through kidneys, excess element filtered into urine
Slow urine flow or saturation of urine with stone composing element
Abrasive crystallized element damages lining of urinary tract
Crystal aggregation, combines with other compounds & form larger
molecule, stone develops

what's going on with lithiasis

Excruciating, unbearable pain (renal colic) or flank pain • Esp. when stone is moving or has obstructed Accompanying N/V, pallor/pale/ashen, diaphoresis Hematuria Bladder distention

how does lithiasis look like in pt

hydroureter

stone occludes ureter, blocks flow of urine, ureter dilates

Hydronephrosis

stone blocks urine in lower urinary tract, kidney fills with urine and enlarges

How do we diagnose lithasis

presentation and symptomology, US, UA esp to check for infection, KUB

Lithiasis emergency

Urinary tract obstruction is an emergency! Treated immediately to preserve
kidney function
Much depends on stone location, size, composition

IV analgesics for immediate pain relief
• Possibly anti-spasmodic
Proper hydration

Lithiasis interventions

the use of sound, laser, or dry shock waves to break the stone into small fragments

Lithotripsy (as known as shock wave lithotripsy (SWL))

scope passed through urethra &
bladder into ureter
Stone visualized & removed using grasping baskets,
forceps, or loops

Ureteroscopy

small tube placed in ureter by ureteroscopy
It dilates ureter, enlarges passageway for stone or
stone fragments

Stenting

removal of stone in ureter or
kidney through the skin

Percutaneous uretero-/nephrolithotomy

Nephrostomy tube care

tube left in place to prevent stone fragments from passing through urinary tract

Antibiotic therapy, if warranted Diet not clinically proven to totally cause, however has shown ability to help control in people who have had recurrent stones • Sometimes prescribed high intake of fluids, fruits, vegetables; low protein; balanced intake of calcium, fats, carbohydrates Stone recurrence may need drug therapy based on composition of stone Strain urine; send passed stone to lab for analysis Education on post-op care, activity, restrictions if appropriate

Lithiasis pt care intervention/ teaching

pyelonephritis

Bacterial infection in the kidney & renal pelvis

Organisms ascend from urinary tract into kidney
tissue (possibly by reflux or from already infected urine in the
bladder [retention/stasis])
Bacteria triggers inflammatory response
Localized edema/inflammation
Infection scatters within the kidney itself, so
widespread fibrosis/scar tissue/thickening
Causes changes in tubular, glomerular, & blood
vessel structure
Filtration, reabsorption, & secretion are impaired
Kidney function is reduced

pyelonephritis

What can cause pyelonephritis

reflux, organism growth in renal stones, manipulation, recent cystitis

Dyspnea, urgency, or frequency of urination CVA tenderness Flank, back, or loin pain Abdominal, often colicky, discomfort, Nocturia, General malaise or fatigue, Fever, Chills Tachycardia Nausea Tachypnea Vomiting

pyelonephritis symptoms

Antibiotic therapy
Pain management
Patient/family/caregiver education r/t drug regimen
Adequate hydration
Proper nutrition, may need consult for registered dietician
Lithotripsy if stones implicated
Patient/family/caregiver education r/t and post-op care or activity
restrictions

pyelonephritis pt care

- Leukocyte esterase & nitrate dipstick & WBC: positive- UA w/ C&S
- Serum kidney test: BUN, creatinine & GFR for baseline kidney function
- serum WBC, C- reactive & ESR to determine immunity response & presence of inflammation
- KUB & CT

labs/imaging for pyelonephritis

- Tylenol to reduce fever if present
- Antibiotics- Broad spec. Until C&S results are known

Drug therapy for pyelonephritis

What is acute glomerulonephritis?

injury to the glomeruli

Auto-immune disorders, genetic involvement
Infectious processes, esp. systemic

these can cause acute glomerulonephritis (AGN)

Edema @ face, eyelids, hands;
possibly ankles, feet, legs, abdomen
s/sx of fluid retention & overload
Urine described as smoky, reddish brown,
rusty, cola color
General fatigue, aches
Anorexia, N/V

AGN symptoms

UA: Proteinuria, Hematuria, RBC casts
decreased GFR
24-hr urine
Throat cx if warranted for strep A

AGN how we diagnose

Antibiotic therapy (Penicillin, Erythromycin, azithromycin)
Symptom management if pain, N/V
Patient/family/caregiver education r/t drug regimen
Principles of infection control
Personal hygiene
Possible sodium, protein, fluid restriction; may need consult for
registered dietician
Possible diuretics
Possible antihypertensives

AGN pt care/interventions

If a patient has acute glomerulonephritis that is not caused by an acute infection, what medication would you expect to be prescribed

Corticosteroids & cytotoxic drugs (to suppress immunity responses & help with inflammation)

Insufficiency leads to failure which leads to end stage
What is it?
Sudden decline in kidney function; over a few hrs. or days F&E balance & acid-balance is no longer able to be maintained

what is acute kidney injury

Rapidly progressive glomerulonephritis often progresses to....

End stage kidney disease

You are discharging a patient with acute glomerulonephritis. You should teach this pt to notify PCP if.....

sudden changes in weight or blood pressure

extracellular volume depletion, decreased renal blood flow, toxic/inflammatory
injury to kidney cells

what can cause acute kidney injury

reduced perfusion to kidneys caused by shock, dehydration, burns, sepsis (leads to hypovolemia, hypotension, hypoperfusion)

prerenal failure

kidney tissue damage caused by disorders like allergic disorders, embolism of renal vessels, (leads to acute tubular damage, postischemia, nephrotoxicity)

intrarenal failure

obstruction caused by tumors, kidney stones, or strictures ( leads to obstructive uropathies [i.e., CAs, hypertrophy, lithiasis, clots])

postrenal failure

Functioning nephrons are overworked
Blood vessel constriction, RAAS activation

What's going on in AKI

Causes of AKI

reduced perfusion to the kidneys, damage to kidney tissue, and obstruction

Oliguria: UOP < 400 mL per 24h in adults
• Diuretic phase may reveal polyuria
Azotemia: retention & buildup of nitrogenous wastes in blood
s/sx of fluid overload

What does AKI look like?

Severity of AKI is based on s serum Cr & d UOP
Serum Creatinine (Cr): 0.5-1.2 mg/dL
BUN: 10-20 mg/dL
UA, Urine electrolyte
Serum electrolytes

How do we diagnose AKI

Early recognition & correction of problems can restore function before damage has occurred
timely implementation of interventions is a must!
Monitor renal function labs (i.e., BUN/Cr, electrolytes, UA, peak & trough levels)
Accurate & careful monitoring of VS
• Maintain a MAP of 60-70 mmHg for adequate perfusion of major body organs; MAP = (SBP + [2 × DBP]) ÷ 3
arterial pressure in vessels perfusing the organs
Careful monitoring of UOP & urine characteristics
Accurate I&O/daily weights
Appropriate hydration, fluid replacement
• Fluid challenge: give 500mL-1L NS over 1 hour
• Monitor for s/sx of fluid overload during & after infusion; assess
response
Electrolyte replacement as warranted
Diuretics only to help excretion of retained fluid & electrolytes

AKI nursing intervention

Vigilance with use of & patient education on nephrotoxic drugs, exposures
• Consult pharmacy for drug dose adjustments
Consult RD r/t potential for protein & muscle breakdown, nutrition support
Educate on f/u with PMD, nephrologist, labs, diet/fluid regimen, dialysis

AKI pt teaching

Gradual decline in kidney function; Irreversible, Progressive
End-stage (ESKD): kidney function is too poor to sustain life

Chronic kidney disease