renal & urology

function of kidneys

produce renin & erythropoietin, activate vitamin D, acid-base balance, electrolyte balance, excretes & conserves water, formation of urine

glomerular filtration rate

100-125 ml/min

ureters function

carry urine from kidneys to bladder

normal urine amount in 24 hours

1000-2000ml

normal urine characteristic

pale yellow to amber color, clear

specific gravity of urine

1.005-1.030

ph of urine

4.5-8.0

normal BUN level

7-20

creatinine normal levels

0.5-1.2 mg/dL

urine is made up of

mostly water, urea, creatinine, uric acid

what happens to the bladder with aging

decreased size & tone → dysuria, urinary frequency, incontinence, urine retention

what happens to the kidneys with aging

lower ability to concentrate urine, lower GFR & nephrons → + risk from nephrotoxic agents, meds, dyes

changes in male renal/urinary system & aging

prostate enlarges → urine retention, difficulty

changes in female renal/urinary system & aging

prone to bladder infections, incontinence, urethral irritation, pelvic floor weakens

normal aging & the urinary system

renal mass smaller, renal flow decrease 50%, decreased tubular function, bladder muscles weaken, lower capacity, delayed voiding reflex

data collection of urinary system

look at all body systems, health hx, pain in flank area, burning voiding, new onset edema, SOB, wgt gain, fluid intake, functional ability

high blood pressure indicates

kidney disease

crackles in lungs & edema indicates

fluid overload

daily weights are best indicator of….

fluid balance

medication and fluid orders depend upon accurate….

intake & output

urine culture is to identify

pathogens, usually bacteria or yeast

urine culture specimen must be collected

before any anti-infectives given → avoid altering the pathogens

uremic frost/skin crystals can indicate

azotemia

pallor, yellow, or gray skin can indicate

anemia, CKD

urinalysis proper collection

AM is best, void or from sterile catheter, 10 mls, examine within 1 hr or refrigerate

random specimens are collected for

cytology

composite urine/24 hr specimen

discard 1st urine

sensitivity test identifies

what anti-infective will kill pathogen

Renal biopsy

thru a small flank incision, monitor: dressing, site, bleeding, VS, 1st void

contraindications to renal biopsy

bleeding, uncontrolled HTN, only one kidney

pre renal biopsy

NPO, mild sedative

IV pyelogram

x-ray using contrast dye to see kidneys, ureters, and bladder

• hydrate before & after

• test for allergies & creatinine

renal angiography

x-ray and dye to see renal arteries

• check allergies, creatinine, & GFR first

• post: check distal extremity pulses and bleeding on dressing

x-ray for kidneys is to detect:

tumor, stones, swollen kidneys

contrast-induced kidney injury

can be nephrotoxic for high risk pts, serum creatinine rises, pt asymptomatic

• low GFR (renal impairment)

• low GFR in DM (neuropathy)

• on nephrotoxic drugs

nephrotoxic drugs

nSAIDS, IV aminoglycosides, tobramycin (Tobrex), alkacin (Amikin), cisplatin (briplatinol), vancomycin, phenylephrine

cystoscopy & pyelogram

inserted into bladder through urethra to remove small tumors, polyps, stones, to dilate ureters, tx enlarged prostate

• monitor urine output post

retrograde pyelogram

contrast media injected into kidneys pelvis

• monitor urine output post

renal ultrasound

noninvasive sound waves to see tract anatomy, no prep needed

stress incontinence

involuntary loss from + abdominal pressure

• associated w/ coughing, sneezing, laughing

urge incontinence

involuntary with abrupt, strong desire to void

disability-associated incontinence

unable to get to BR d/t health/environmental barriers

overflow incontinence

bladder overdistention

total incontinence

continuous, unpredictable loss of urine, can be grouped into with disability-associated

urinary retention acute causes

anesthesia, local trauma, meds

urinary retention chronic causes

enlarged prostate, meds, strictures, tumors

monitor these for urine retention

output, bladder distention, bladder scan (residual 150-200ml indicates need for tx, catheters)

indwelling catheter uses

burns, neurogenic bladders, shock, urinary tract obstruction

incontinence is not a reason for…

catheterization

intermittent catheters

lowest risk for infection, pts can do it, “best”

suprapubic catheters

indwelling, thru incision in lower abdomen into bladder

• monitor dressings, keep clean & dry, secure cath to reduce tension

most common cause of UTIs

e. coli

UTIs are the….

most common hospital-acquired infection

pyelonephritis

common, costovertebral tenderness, high fever, chills, N/V

UTI complication

urosepsis, serious, common in older adults

data collection for utis

predisposing factors: catheter, recent 3-way cath, surgery, voiding patterns

• s/s: urgency/frequency, burning, foul-smelling urine, hematuria, pelvic pain

an obstructed urine flow is always

a significant issue, can be partial/complete, unilateral/bilateral, slow or rapid onset

• distends kidney, pressure can damage kidney tissue → CKD

urethral strictures

lumen narrows d/t scar tissue

• from injury, STI, tissue trauma from catheters/surgical instruments, cancer, enlarged prostate

urethral stricture is more seen in

men

s/s: less stream, dysuria, frequency, frequent UTIs

renal calculi

small, hard stones in tract

ureterolithiasis

ureter stones

stones less than 5 mm

can be passed in urine, otherwise painful & need tx

nephrolithiasis

kidney stones

• s/s flank/side/low abd pain, intense urge, frequency, dysuria, lower output, hematuria, N/V

s/s of bladder stones

hematuria, oliguria w/ obstructed bladder outlet

prevention of stones

hydration, diet, exercise

diagnosis of stones

blood test (BUN, calcium, uric acid, creatinine), urinalysis (hematuria, crystals, ph), 2 24 hr collections, CT, renal ultrasound, abd x-ray, IV pyelogram

therapeutic interventions for small stones

hydrate, analgesic, alpha-blocker (tamsulosin)

interventions for large stones

IV fluids, pain control, thiazide diuretics, allopurinol (aloprim), lithotripsy (extracorporeal shock wave)

surgeries for stones

cystoscopy, cystolitholapaxy, cystostomy, ureterolithotomy, percutaneous nephrolithotomy, nephrostomy tubes, nephrolithotomy, pyelithotomy

complications of stones

UTIs, hydroureter, hydronephrosis, shock, sepsis, CKD

hydronephrosis

obstruction causes urine backup → kidney enlarges → pressure increases → damage → kidney shuts down

hydronephrosis tx

catheter, stends, nephrostomy tube, I&O (record cath & nephrostomy output separately)

renal trauma data collection

injury hx, inspection of abdomen & flank area

• s/s: bruising, swelling, pain, hematuria

• dx tests: CT, urinalysis, IV pyelogram, MRI

polycystic kidney disease

hereditary, multiple cysts in kidney

• s/s: dull, heaviness in flank/back, hematuria, HTN, UTI

• progressive, no tx

nephrotic syndrome

lg amnts of protein loss in urine from + glomerular membrane permeability

• serum albumin/protein decrease

• causes edema, scites, anasarca

• kidneys dying

in nephrotic syndrome the liver

produces lipoproteins → foamy urine

nephrotic syndrome may be caused by

lupus

nephrotic tx

tx cause (lupus), anticoagulants to prevent thrombosis

nursing & nephrotic syndrome

edema (daily wgts, I&O, abominal girth, protect edematous tissue), prevent infection, malnutrition, and thrombosis

nephrosclerosis

HTN damages kidneys from sclerotic changes

• use antihyperten

glomerulonephritis

inflammatory disease of glomerulus

• s/s: oliguria, HTN, electrolyte imbalances, edema, flank pain

• dx: + in creatinine & BUN, urine dark/foamy, urinalysis, ultrasound, x-ray, biopsy

acute kidney injury

sudden loss of kidney function, azotemia, oliguric, may be from hypoperfusion, direct injury, hypersensitivity, may recover if cause removed

prerenal failure can be from

shock

check these before contrast media & nephrotoxic meds

GFR & serum creatinine

• to prevent acute kidney injury

interventions for acute kidney injury

tx cause, dialysis, continuous renal replacement therapy (removes fluids/solutes - esp for unstable pts, blood flows thru hemofilters, excess into bag)

chronic kidney disease

gradual decrease in function, can be from: diabetic neuropathy, HTN, nephrosclerosis, glomerulonephritis, autoimmune disease

protein in urine should be…

less than 20

normal glomerular filtration rate GFR

100-120

creatinine normal level

0.5-1.2

normal BUN level

8-21

What will he seen in pt with CKD

SOB, electrolyte imbalance, anemia

CKD interventions

High calorie/low protein diet, low sodium/potassium/phosphorous, +calcium & vitamins, fluid restriction, dialysis

CKD meds

Anti HTN, phosphate binders, diuretics, vit D/calcium supplement, potassium reducers (calcium gluconate iv), sodium polystyrene sulfonate (Kayexalate), patiromer (veltessa)

Nursing & CKD

excess fluid volume (wgt, I&O monitoring, restrict fluid, monitor for retention), electrolyte imbalance (monitor levels, restrict diet, monitor for arrhythmias)

hemodialysis

Artificial kidney removed waste products & excess water from blood

Hemodialysis access

Vascular, can be temp or central vein, or permanent in arteriovenous fistula/vascular access graft

Permanent vascular access care

• post-op fistula or graft creation, neuro checks, pain, elevate extremity, verify thrill, bruit patency, protect access (no BP on side, no lab draws), educate pt

Peritoneal dialysis

done by pt, membrane separated from semipermeable, excess waste & fluid removed from blood

Peritoneal dialysis complication

Peritonitis after 2 years of use

SE of anti rejection drugs for kidney transplant

Cancer, immune issues