Nursing 313 Exam 3

Acute Kidney Injury

Condition characterized by an acute, rapid loss of renal function. Rapid and progressive azotemia

Azotemia

buildup of nitrogen and nitrogenous waste products

Kidney changes and AKI

Azotemia, uremia, progressive increase in K, oliguria

Prerenal causes of AKI

external causes, not related to the anatomical structures of the urinary system. Reduce renal blood flow and lead to decreased glomerular perfusion and filtration.

intrarenal causes of AKI

direct damage to the renal parenchymal tissues(nephrons) resulting in impaired renal function

Postrenal causes of AKI

mechanical obstruction of the lower urinary tract

Phases of AKI

Initiating phase, oliguric phase, diuretic phase, recovery phase

Initiating phase of AKI

onset-when AKI first occurs ends when symptoms appear. can last for hours to days

Oliguric phase

does not always occur-urine output decreases because of tissue damage

Triggering event of AKI

Usually arises from prerenal condition that results in ~25% decrease in circulating volume.

Compensatory mechanisms in initiating phase

cause release of substances to preserve blood flow to essential organs. Substances include Angiotensin II, aldosterone, norepinephrine, and ADH

Release of compensatory mechanisms results in

vasoconstriction, sodium and water retention, and decreased urine output.

if prerenal cause is corrected during the _______ phase, AKI is completely reversible

initiating

urine output during oliguric phase

below 400mL/day

Results of decreased GFR in oliguric phase

increase in BUN/creatinine, electrolyte abnormalities, acidosis, fluid overload, urine with fixed specific gravity and high sodium concentration

Diuretic phase of AKI

occurs when the cause of the AKI has been corrected, kidneys want to get rid of the fluid that has accumulated. Osmotic diuresis will occur resulting from high urea levels

urine output during diuretic phase

3-5L/day

Risk of diuretic phase

patients can experience severe fluid loss as a result of increased urination, resulting in dehydration and electrolyte imbalances

Recovery phase of AKI

begins as kidneys begin to return to their excretory function, GFR increases to 70-80% of normal, fluid and electrolyte balance normalizes

Clinical manifestations of AKI

signs of fluid overload(edema, pulmonary edema, SOB, HF, hypertension, dysrhythmia, chest pain), electrolyte impalances, anorexia, nausea, constipation, confusion, lethargy, seizures, coma

Electrolyte imbalances in AKI

Increased K, Phosphorus, BUN, creatinine, Decreased Ca, Na, Metabolic acidosis

Goals of AKI management

eliminate the cause, prevent complications

supportive care in AKI

ensure adequate fluid volume, correct fluid overload, correct biochemical abnormalities. Monitor hydration status(BP, HR, pulses strict I+O)

Medications for AKI

Loop or osmotic diuretics to treat fluid overload, treatment for hyperkalemia(possibly insulin), nephrotoxic agents must be avoided

Nutrition for AKI

adequate CHO, fat, and protein to prevent catabolism, K and Na are restricted

hyperkalemia

risk of life threatening cardiac dysrhythmias can occur due to increased K

Treatment of hyperkalemia

IV calcium gluconate or CaCl to stabalize myocardium, enhance cellular reuptake of K(insulin, albuterol, bicarbonate), enhance elimination of K(kayexelate, lasix, hemodialysis)

Dialysis for AKI

may be used short term to allow recovery of renal tissue, while preventing life-threatening complications.

Indications for dialysis for AKI

severe fluid overload resulting in HF or respiratory distress, elevated K with ECG changes, severe acidosis, altered mental status, pericarditis, pleural effusion, cardiac tamponade

Neohrolithiasis

calculous(stone) in kidney

Causes of nephrolithiasis

crystals precipitate out and unite to form a stone, 80% calcium 20% uric acid or other minerals

Common sites for kidney stones

uretropelvic junction, lower third of ureter as it crosses the iliac vessel, ureterovesical junction

Metabolic risk factors of kidney stones

abnormalities that result in increased levels of calcium, oxaluric acid, uric acid, or citric acid(ie: gout)

Diet factors of kidney stones

large intake of dietary proteins(leads to incresed uric acid), excessive amounts of tea or fruit juice(leads to increased urinary oxylate), large intake of Ca, low fluid intake

Lifestyle and climate factors of kidney stones

Warm climates cause increased fluid loss and increased solute concentration in urine, immobility, sedentary occupation

Clinical manifestations of kidney stones

renal colic-severe pain causing distention and obstruction of flow, nausea and vomiting, hematauria

Diagnostic study for kidney stones

CT scan will identify the caluli and assess obstructive uropathy

Complications of kidney stones

pelonephritis, urosepsis, irreversible renal damage.

rise in BUN and createnine indicates ________ of a kidney stone is required in order to __________

aggressive treatment in order to avoid complications

Uretral stent

Drains urine out of the kidney bypassing stones

Nephrostomy Tube

Catheter inserted to preserve renal function when complete obstruction of ureter is presant. Tube is inserted into the kidney through the back

Nursing care of nephrostomy Tube

catheter should never be kinked or compressed, irrigation of 5mL sterile saline with strist aseptic technique. Patients must drink 2-3 L fluid daily to decrease risk of complications

Trial of passage of kidney stones

opportunity to pass stone on their own. All urine is strained to check for stone, treatment with pain medications, antiemetics, and alpha adrenergic blockers(relax smooth muscle)

ESWL therapy

used for both renal and ureteral stones

Surgical removal of kidney stone

for if stone is >10 mm causing severe obstruction. Pain is uncontrolled or pt has an infection, impaired renal function.

Ureteroscopy

surgical procedure for mild or distal ureteral stones. Under general anesthesia, stone is identified and removed, larger stones may need to be broken up first

Percutaneous Nephrolithiotomy

used for larger stones >2cm and staghorn stones, under anesthesia nephroscope inserted through skin. kidney stone can be fragmented and fragments are removed. Nephrostomy tube often left in place to make sure ureter is not obstructed

Complications of cytoscopic procedures

hemorrhage, retained stone fragments, infection. Hematauria common and typically resolves on its own

nutrition after kidney stone resolves

high fluid intake ~3L/day to produce urine output of 2L/day. Prevents supersaturation of minerals, water is preferred. Increased fluid is especially important for pts at risk for dehydration

Diet after kidney stones

calcium restriction not routinely implemented unless calcium is known cause. Limit oxylate rich foods, limit purines

Risk factors for kidney cancer

smoking, tobacco, family history, obesity, HTN, asbestos, gasoline, kidney disease

CM of kidney cancer

No early S+S, many people go undiagnosed until disease has significantly progressed. causes symptoms by compressing, stretching, or invading nearby structures.

Symptoms of kidney cancer

flank pain, flank mass, hematauria, weight loss, fatigue, fever, hypertension, anemia

Robsons system of staging-stages renal carcinoma

1-limited to kidney, small tumor
2-spreading to peri-renal fat but confined
3-invasion of renal vein or vena cava, regional lymph node involvement
4-presence of metastasis

Medical management of kidney cancer

resistant to chemotherapy, biological immunotherapy to boost immune system to attack abnormal cells, targeted medications to block growth

Radial nephrectomy

For stage 1 and 2 tumors, removal of affected kidney, adrenal gland, fascia, ureter and draining lymph notes

Partial nephrectomy,

early or small stage cancer, remove just the tumor

Radiation therapy for kidney cancer

used palliatively in inoperable cases where there is significant metastasis

Risk factors for bladder cancer

smoking, rubber, chemical, coal and aluminum industries, chronic infection or inflammation, cervical cancer treatment, Cytoxan

Clinical manifestations of bladder cancer

microscopic hematauria, bladder irritability(dysuria, frequency, urgency)

TNM staging of bladder cancer

T1-non-muscle invasive cancer(only affecting inner lining)
T2-T4-invasive cancer, extended through bladder

Jewett-strong-marshall classification of bladder cancer

classifies bladder cancer as superficial, invasive, or metastatic.

Medical management of bladder cancer

Topical chemotherapy, immunotherapy, targeted therapy

Intravesical therapy for bladder cancer

local instillation of chemotherapeutic agent delivered directly into bladder by urethral catheter. Done for 6-12 weeks, agents are retained for 2 hours and then drained back out, pt changes position every 15 minutes

Side effects of intravesical therapy

Most patients have irritative voiding symptoms and hemorrhagic cystitis following therapy

Nursing responsibilities for intravesical therapy

encourage increased fluid intake, encourage smoking cessation, assess for symptoms of UTI, encourage follow ups with Dr, address concerns

Surgical management of small bladder cancers

excision or removal of tumor through fulguration or laser ablation. Radiation indicated post-operativly

Surgical management of muscle invasive bladder cancers

Cystectomy(partial or radical)

Radical cystectomy

removal of bladder, lower ureters, sometimes urethra, (for men) prostate, seminal vesicles (in women) anterior vagina, fallopian tubes, uterus,

Indication for urinary diversion

bladder cancer, neurogenic bladder, congenital abnormalities, strictures, trauma of bladder, chronic infections

Cutaneous ureterostomy

urine diverted into stoma in the abdomen, can cause significant complications

Ileal conduit

Short segment of ileum converted into a condiut, ureters are connected together and brought through abdominal wall, no voluntary control

Neobladder with continent catheterization

intra-abdominal urinary reservoir that can be catheterized. Internal pouch created and low pressure of the reservoir prevents urine from leaking. Patient self catheterizes every 4-6 hours to drain urine

Orthotopic neobladder

30 cm of small intestine to create a bladder that is anatomically in the same position as the bladder and uses the patients external sphincter for continence.

Ideal candidates for orthotopic bladder reconstruction

Cancer must not invade bladder neck or urethra, normal renal and liver function, longer than 2 year life expectancy, adequate motor skills, no history of IBD, normal BMI

preoperative management of urinary diversions

extensive pre-op teaching, stoma care, social aspects of stoma living, self-catheterization, potential incontinence

Postoperative management of urinary diversions

prevent post-op complications(atelectasis, shock, UTI, paraliytic ileus), prevent injury to stoma, maintain urinary output, skin integrity, catheterization

Discharge teaching or urinary diversions

signs of obstruction or infection, care of ostomy, emergency phone lines, support groups, follow up visits,

Epididymitis

Acute, painful inflammatory process of the epidiymis. Usually unilateral with swelling that can progress signifiantly

Causes of epididymitis

Infection(Gonorrhea or Chlamydia), trauma, urinary reflux down the ductus deferens

Treatment of epididymitis

Antibiotics, elevating scrotum, ice packs, analgesics(NSAIDs)

Prostatitis

Group of inflammatory and non inflammatory conditions affecting the prostate gland.

Acute and bacterial prostatitis

result from bacteria reaching the prostate gland through the urethra, bladder, or lymphatic channels

Clinical manifestations of prostatitis

Fever, chills, back pain, perennial pain, acute urinary symptoms(dysuria, urinary frequency, urgency, cloudy urine) may develop acute urinary retention

Complications of prostatitis

Epidiymitis, cystitis, sexual function changes(painful ejaculation, decreased libido, erectile dysfunction, abscess)

Diagnosis of prostatitis

Urinalysis culture and sensitivity, CBC, blood cultures, PSA

Management of prostatitis

Antibiotics, anti inflammatories, management of fever, sitz bath, a-adrenergic blockers, prostatic massage, catheterization, push fluids

benign prostatic hyperplasia

benign enlargement of the prostate gland. Most common urologic problem in adult males

Initial symptoms of BPH

bladder can compensate for mild resistance, few symptoms occur

Obstructive symptoms of BPH

Difficulty starting urine flow, decrease force of urine stream, interruptions during urination, dribbling at end of urination

Bladder change symptoms in BPH

urgency, frequency, feeling of bladder fullness, frequent awakening to urinate, incontenince

AUA scoring of BPH

0-7 mild
8-19 moderate
20-35 severe

Bladder outlet obstruction

Acute urinary retention caused by prostate enlargement. Can cause UTI or potential sepsis, severe cases can cause renal failure due to damage or pyelonephritis

Hydronephritis

Backflow of urine into renal caliculi due to inability to void

Diagnostic studies for BPH

Digital rectal exam, PSA, post void residual, transrectal ultrasound, cytoscopy

Goal of BPH treatment

Restore bladder drainage, relieve patient symptoms, prevent or treat complications

"watchful waiting" for BPH

no symptoms or mild symptoms, yearly DRE to examine new growth, dietary changes that will reduce inflammation, avoid medications that cause retention or increased diuresis, timed voiding schedule

5a-reductase inhibitors for BPH

anti-androgens-work to reduce the size of the prostate. Can take 3-6 weeks to work and have significant side effects such as gynecomastia, ED, and decreased libido, difficult for patient compliance

a-adrenergic receptor blockers

act on alpha receptors in prostate to cause relaxation of smooth muscle, decreases constriction of urethra to facilitate urine flow. Symptomatic relief but does NOT treat cause. Can cause dizziness and orthostatic hypotension

Alternative therapies for BPH

Intermittent catheterization, saw palmetto, african plum, cerniltron, star grass. No reason pt cannot take these unless they care known to be harmful