Renal and Elimination Disorders NUR 310

•Functions of the Kidney

•Functions of the Kidney

▫Urine formation

▫Excretion of waste products

▫Regulation of electrolytes

▫Regulation of acid-base balance

▫Control of water balance & blood pressure

▫Regulation of red blood cell production

▫Synthesis of vitamin D to active form

▫Regulates calcium & phosphorus balance

Anatomy Structures:

▫Kidneys

▫Ureters

▫Bladder

▫Urethra

Internal Structure of the Kidney

Age Related Changes

•Ages 30-90

•7^th decade of life

•Atherosclerosis

•Decreased blood flow

•Altered hormone levels

•Loss of elasticity –Females

•Prostate enlargement – Males 

Health History & Assessment

•Pain

•Past history of UTI

•Fever, chills

•Changes in urinary pattern

•Dysuria

•Nocturia

•Hematuria

•Anuria

•Nutritional lifestyle patterns

•Weight gain or loss

•Medications

•Smoking

•Vital signs

•Intake and output

•Weight; BMI

•Inspect

•Palpate

•Percussion

•Auscultation

•NORMAL:

•No CVA tenderness

•Non-palpable kidney, bladder

•No palpable masses

Diagnostic Assessment

•Color: amber yellow

•Odor: aromatic

•Protein: random, 0-trace

•Glucose: none

•Ketones: none

•Bilirubin: none

•Specific gravity: 1.003-1.030

•Osmolality: 300-1300

•pH: 4.0-8.0, avg 6.0

•RBCs: 0-4

•WBCs: 0-5

•Casts: none to occasional

•Culture: no organisms

Lab Tests and Imaging Studies

•Review the description, purpose and nursing responsibilities

•Urinalysis

•Creatinine clearance: no calculation; no values; just purpose and nursing responsibilities

•Composite urine collection

•Urine clean catch

•Concentration test (aka: specific gravity)

•Residual urine

•Protein dipstick

•Quantative protein

•BUN, Creatinine, K+, Sodium, Calcium, Phos, Sodium Bicarb

•Renal biopsy

•Cystoscopy

•MRI

•Renal Ultrasound

•CT

•KUB

•Renal Arteriogram 

Nursing Care of the Patient Undergoing Diagnostic Testing of the Renal-Urologic System—Assessment

•Patient knowledge

•Psychosocial and emotional factors; fear, anxiety

•Urologic function, include voiding habits/pattern

•Fluid intake

•Hygiene

•Presence of pain or discomfort

•Allergies

Urinary Tract Infection

•Bladder & its contents are typically free of bacteria

•Females >Males

•Invasion of bacteria

•E. Coli

•Etiology

•At Risk Patients

Urinary Tract Infection

•Upper versus Lower

•Urosepsis 

•Uncomplicated versus Complicated

•CAUTI

UTI: Diagnostics

•Diagnostics

• Dipstick Urinalysis

–+Nitrites

–+WBCs

–+Leukocyte Esterase

Urine Cultures / CT and US of abdomen and Pelvis

UTI Medical Therapy

•Uncomplicated UTI

•Phenazopyridine àPain

•Antibiotics

• trimethoprim/sulfamethoxazole (Bactrim)

• trimethoprim alone (in patients with sulfa allergy)

• nitrofurantoin (Macrodantin, Macrobid)

• fosfomycin (Monurol)

•Recurrent UTI

•Phenzopyridine à Pain

•Antibiotics:

• trimethoprim/sulfamethoxazole, nitrofurantoin

• Sensitivity-guided antibiotic therapy

• Prophylactic antibiotic regimen

• Consider post-coital antibiotic prophylaxis

UTI Nursing Interventions

•Recognize AT RISK individuals

•Empty bladder and stool

• Routine void Q3-4 hrs (minimum)

•Wipe front to back

•Increase PO water intake

•Cranberry

•Remove catheters early; avoid unnecessary catherization

•Avoid contaminating urine samples

•Perineal care

•Void after intercourse

UTI Nursing Interventions (pt. 2)

•Frequent rounds; offer bedpan or frequent toileting

•Early removal of indwelling catheters

•Handwashing

•Placement of “foley” is STERILE

•Avoid bladder irritants

•Localized heat

•Medication education

•Complete medical therapy

•When to call the healthcare provider

Pyelonephritis

•Inflammation of the renal parenchyma and collecting system

•Etiology

• Bacterial infection

• Urosepsis

• Pre-existing factors

Pyelonephritis – Clinical Manifestations

•Symptoms (6)

• Mild fatigue

• Chills

• Fever

• Vomiting

• Malaise

• Flank pain

•Diagnostics (2)

• Urinalysis

• Ultrasound / CT

Pyelonephritis (Acute & Chronic)

ACUTE (7)

•H&P

•U/A + C/S

•Imaging studies

•Labs

•Assessment

•Mild Symptoms: Drug Therapy

•Severe Symptoms: Drug Therapy

CHRONIC (5)

•Kidneys become small, atrophic, shrunken and lose function

•Etiology: recurrent infections

•Imaging and Biopsy to confirm diagnosis

•One vs Both kidneys

•Progression to ESRD

Urinary Tract Calculi

•Nephrolithiasis (kidney stone disease)

•Males

•20-55 yrs of age

•Reoccur in 50%

•Summer → Dehydration theory

•Gender Differences  

Urinary Tract Calculi: Risk Factors

•Metabolic → Abnormalities that result in increased urine levels of calcium, oxalate uric acid, or citric acid

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

•Diet

Large intake of dietary proteins that increases uric acid excretion

• Excessive amounts of tea or fruit juices that elevate urinary oxalate level

• Large intake of calcium and oxalate

• Low fluid intake that increases urinary concentration

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

•Lifestyle

• Sedentary occupation, immobility

Urinary Tract Calculi: Types of Stones

•Review Characteristics, Predisposing Factors and Treatment

• Calcium phosphate

• Calcium oxalate

• Uric acid

• Cystine

• Struvite (magnesium ammonium phosphate)

Urinary Tract Calculi: Diagnostics & Interprofessional care

Diagnostics

•Non-contrast CT

•U/A

•KUB

•(IVP) Intravenous Pyelogram

•Stone Retrival

▫Patient may pass

•Check urine pH

Interprofessional care

1) Manage the Attack

2) Etiology

H&P

OTC and Prescribed Meds

Labs, Diagnostics

Lifestyle

Diet

Tamsulosin or Terazosin

Acetohydroxamic Acid

Antibiotics

Invasive Treatment

Cystoscopy

Percutaneous Removal

Lithotripsy

Surgery

Ureteral Stent

Nursing Interventions for Kidney Stones

•Pain relief

•Monitoring for complications

•Promote fluid intake: 2-3L intake and 2L output

•Encourage ambulation

•Strain all urine

•Urine Cx every 1-2 months

•Medical therapy

•Diet Therapy

•Vital Signs (temperature)

•Patient education

▫Report decreased urine output

▫Report sudden increase in pain

▫If stent, hematuria expected, monitor for fever

Benign Prostatic Hyperplasia (BPH) / RF

•Benign enlargement of the prostate gland

•Common in adult males

•50% of men will develop BPH

•Cause is unknown

•Enlargement of gland can lead to urethra obstruction

•Risk factors: aging, obesity, lack of physical activity, alcohol consumption, erectile dysfunction, smoking, and diabetes.

BPH (Diagnostics/ Goals/ Tx)

•Diagnostics: H&P, prostate can be palpated by digital rectal exam, urinalysis with culture, Prostate-specific antigen (PSA) to rule out prostate cancer.

•Goals: Restore bladder drainage, relieve patient’s symptoms, prevent/treat complications of BPH

•Treatment: Conservatively, Medications, Surgery

Drug Therapy

•5α-Reductase inhibitors

• α-Adrenergic receptor blockers

• Erectogenic drugs

Nursing Implementation

•Preoperative care for TURP

• Administer antibiotics

  • Treat UTIs

▫Restore urinary drainage

• Coudé – curved-tip catheter

• Filiform – rigid catheter

• Aseptic technique very important in preventing infection

▫rovide patient opportunity to express concerns over alterations in sexual function

▫Inform patient of possible complications of procedures

• Decreased or absent ejaculate volume

• Retrograde ejaculation

Nursing Implementation

•Maintain Patency with flushing and irrigation

•Continuous versus intermittent irrigation

•Sterile solutions

•Clears out clots and debris

•Used to instill medications into bladder

•Maintain closed system

Nursing Implementation Post-op

•Postoperative care for TURP

• Postoperative bladder irrigation

• Stool softeners and high fiber diet to prevent straining

• Treat bladder spasms

• Catheter care

• Teach Kegel exercises

• Observe for signs of infection

• Manually on an intermittent basis

• Continuous bladder irrigation (CBI)

  • Remove blood clots

  • Ensure drainage of urine

  • Use aseptic technique

•Assess for complications

• Hemorrhage

• Bladder spasms

• Urinary incontinence

• Infection

Nursing Implementation: Ambulatory and Home Care

•After prostate surgery

• Return to urinary continence

  • Refer to continence clinic if not normal within 12 months

• Use of penile clamp, condom catheter, incontinence pads or briefs to manage dribbling and continue socialization activities

Health Promotion

•Early detection and treatment

•55-69 greatest benefit from PSA

•Initial Q2 years

•Avoid irritants

•Cold Meds

•Patient Education