Renal

Normal things to find in urine

urea

creatinine

potassium, Na, Cl, phosphate

uric acid

urobilinogen

abnormal things to find in urine

glucose

blood

albumin/protein

ketones

bacteria

WBC

crystals

Acute Kidney Injury (AKI)

Sudden decline in kidney function that is often treatable and reversible

causes of AKI

Pre-renal issues (hypovolemia, hypotension, obstruction, vasoconstriction)

Intra-renal (inflammation, glomerulonephritis, nephrotoxic meds, ischemic damage)

Post-renal (ureter, urethra, bladder obstruction)

How do we treat AKI

treat the underlying cause (if hypovolemia give fluids, if infection give abx, etc)

Common nephrotoxic agents

- ibuprofen/advil

- Gadolinium (contrast dyes)

- Acetaminophen

- Macrolides Abx (gentamicin, erythromycin, -mycin/micin)

Why do patient with kidney disease develop anemia?

reduced kidney function reduces erythropoietin leading to reduced production of RBC => anemia

Chronic Kidney Disease (CKD)

progressive, irreversible loss of kidney function

Some main causes of CKD

1) Diabetes Mellitus (injury of the endothelial layers of the blood vessels)

2) Hypertension (uncontrolled)

3) AKI

S/Sx of Chronic Kidney disease

- itching (build up of urea in the blood and on skin)

- fatigue (anemia and decrease CO due to fluid build up)

- increase waste products in blood (urea and amonia)

- HTN (fluid retension)

Normal GFR

125ml/min/1.73m^2

General Trends of CKD Stages

Stage 1: kidney damage with normal GFR (≥90)

Stage 2: mid GFR impairment (60-89)

Stage 3: moderate GFR impairment (30-59)

Stage 4: severe impairment of GFR (15-29)

Stage 5: end-stage (GFR<15) almost no urine output at this point

Types fo dialysis

hemodialysis and peritoneal dialysis

hemodialysis

the process by which waste products are filtered directly from the patient's blood using an external device with semipermeable membranes that allow for waste to be diffused out of the blood.

What do you need to assess before dialysis

1) BP (should be high before dialysis)

2) Port site (for signs of infection)

3) Electrolytes (esp potassium)

4) medications

Hemodialysis Catheter

Large lumens accommodate hemodialysis, usually temporary

Nursing notes about hemodialysis catheter

- red and blue caps SHOULD NOT BE USED FOR ANYTHING OTHER THEN DIALYSIS!!!!!

- assess frequently for signs of infection

- places into he vena cava from subclavian so high risk of infection

Internal Arteriovenous Fistula and Graft

- Surgical procedures... take 2-3 months to mature

- take artery and vein, cut them and sew them together leading to blood flow from the artery into the vein to increase strength of vein walls to allow for the fluid volume from dialysis to be accommodated

Fistula Nuring Considerations

1) Do not use it for IV sticks

2) Do not use that arm for blood pressure readings

3) Assess for trills and bruits (normal findings)

Peritoneal Dialysis

the lining of the peritoneal cavity acts as the filter to remove waste from the blood

used when ESKD is <10% GFR

high risk of sepsis and peritonitis

Peritoneal Dialysis Nursing interventions

- assess for signs of infection at insertion site

- assess for signs of peritonitis

- help reposition patient if they are SOB due to fluid in abdomen

Concerns with Peritoneal Dialysis

there is less monitoring so increased risk of fluid overload and infection

S/Sx of peritonitis

- abd pain and rigid abdomen

- cloudy dialysate solution

- Fever/chills

- elevated WBX

- malaise

Med consideration for dialysis

Important to think about med administration before dialysis b/c many will immediately be removed from the bloodstream during dialysis

1: EPO medications (darbepoetin) and iron

2: electrolyte supplements

3: blood pressure meds

Sodium Polysterene (Kayexalate)

bind to K so it can be excreted in feces to help to lower K levels in the bloodstream

Renale Diet

- low Na

- low K

- low phosphorus

- may reduce protein

Why is phosphorus an issue with CKD

extra phosphorus in the blood stream can pull calcium in the blood and lead to deposits in blood vessels, soft tissue, heart, etc.

Foods high in phosphorus

- dark colas or beers

- deli meats

- protein foods

- dairy

Normal urinary output

1ml/kg/hr or ~30ml/hr

Oliguria

decreased urinary output

<0.5ml/kg/hr

anuria

absence of urine

<50mL/day

Bacteriuria

bacteria in the urine

Dysuria

painful urination

enuresis

involuntary discharge of urine

Frequency

frequent voiding (more then every 3 hours)

Hematuria

blood in the urine

hesitancy

delay, difficulty in initiating voiding

incontinence

inability to control bladder and/or bowels

nocturia

excessive urination at night

polyuria

excessive urination

Proteinuria

protein in the urine

Azotemia

urea and nitrogenous waste in the blood

urgency

strong desire to void

1 c = ____ oz

8 oz

30mL = __ oz

1 oz

1 cup = ___ mL

240mL (also 8oz)

BUN

blood urea nitrogen

indicates kidney function

Normal BUN

5-20mg/dL

Why would BUN be high?

reduced kidney function, dehydration, increased protein consumption

Creatinine

nitrogenous waste excreted in the urine, indicated GFR

What can impact creatinine?

age (higher in older patients due to lower kidney function)

sex (muscle mass)

race.......not clear if this is valid.....

BUN/Creatinine Ratio

10:1 to 20:1

if BUN is high and Cr is normal probably dehydration/protein

If both are high but ratio is normal means reduced kidney function

Urine specific gravity normal values

1.003-1.030

Urinary Tract Infection

microbial infection of any part of the urinary tract, often caused from E. coli from anus/GI

Risk factors for UTI

- female

- sexual intercourse

- indwelling catheter

- diabetes (glucosuria)

- urinary tract obstruction/urinary stasis

UTI Types

Lower UTI:

- Cystitis (bladder)

- Urethritis (urethra)

- Prostatitis (prostate)

Upper UTI:

- pyelonephritis (kidney infection)

pyelonephritis

Increased risk of developing upper UTI following lower UTI with presence of vesicoureteral reflux

can cause AKI

Uncomplicated UTI

- often asymptomatic

- female, not pregnant, no weakened immune system

- can appear as delirium in elderly patients

- lower UTI infections

S/Sx of Uncomplicated UTI

pyuria (burning upon urination)

dysuria

frequency

urgency

cloudy

WBC, RBC, nitrites in urine

bacteria in urine

Complicated UTI

occurs in individuals with other health problems, males, harder to treat, pregnant patients, upper infection

Complicated UTI S/Sx

- fever

- suprapubic pain

- flank pain

- CVA pain (often unilateral)

Patient Edu for UTI

- drink 8-10 glasses of water per day

- void q2-3hr

- females should void after sex

glomerulonephritis

inflammation of the glomeruli of the kidney

- more than just WBC/RBC/bacteria in urine (includes protein)

- severe kidney

- kidneys can't filter fluid (severe decrease in GFR)

- may need dialysis

Urinary Calculi

- kidney stones

- most common urological problem in adults

- more common in males

Causes: dehydration, excessive calcium or uric acid, urinary stasis, unknown

Urinary Calculi s/sx

flank pain

hematuria

CVA tenderness

Diagnosis of Urinary Calculi

KUB (x-ray of kidneys, ureters, bladder)

Urinalysis

Stone anlysis

Treatment of Urinary Calculi

- encourage fluid intake (3-4L/day)

- analgesic (not NSAIDs)

- give diuretics or antibiotics

- Alpha blockers: tamsulosin (flomax)

- Lithotripsy

Lithotripsy

- surgical crushing of a stone with shockwaves

- hematuria is normal after

- used for larger stones

- painful

Most common type of kidney stones and how to treat

- calcium oxalate stones (70-80% of cases)

- restrict oxalate

Foods high in oxalate

spinach, rhubarb, beets, nuts, dark chocolate, tea, wheat bran, strawberries

Benign Prostatic Hyperplasia

- benign growth of cells within the prostate gland

- by age 60, 50% of males have BPH

- PSA levels will be elevated

Meds for BPH

- Alpha Blocker: tamsulosin (flomax) to relax muscles in neck of bladder

- 5-alpha reductase inhibitor: finasteride (proscar) blocks an enzyme that changes testosterone to another hormone that causes growth of prostate

S/Sx of BPH

- sensation of not emptying bladder completely

- frequency with urination

- interruption of urine stream

- difficulty postponing urination

- weakness of urine stream

- need to strain to begin urination

- frequency of urination at night (nocturia)

BPH treatment

Transurethral resection of the prostate (TURP):

TURP

Insertion site: tip of penis, through urethra to trim away excess

prostrate

TURP nursing care

- hematuria is normal after for 12 hours

- assess for signs of hemorrhage

- dribbling after the catheter removal is normal in post-op

- patient should report retrograde ejaculation