Med 2 Exam #3 Kidney/Urinary

Urinary tract infections (UTIs)

most common outpatient infection

Causes:

-most common pathogen is E. coli

-other common causes include other microorganisms s/a cadida, pseudomonas, stpylococcus, and streptoccoci group B

Classifications:

-upper or lower depending on its location w/i the urinary system

• pyleonephritis, cystitis, urethritis, urosepsis

-uncomplicated = otherwise normal urinary tract and usually only involves the bladder

-complicated = underlying structural or functional problem of urinary tract

• obstruction, stones, catheters, abnormal GU tract, acute kidney injury, CKD, kidney transplant, diabetes, or neurologic disease

• has developed antibiotic resistance, immunocompromised, has pregnancy-induced changes, or has recurrent reinfection

Patho:

-urinary tract above urethra normally sterile

-defense mechanisms help prevent UTIs

• normal voiding w/ complete bladder emtyping, UVJ competence, ureteral peristaltic activity that propels urine towards bladder

-organisms from from perineum ascend urethra

-most common health-care associated infection (HAI)

UTI manifestations/ diagnostics

range from painful urination in uncomplicated urethritis or cystitis to severe systemic illness w/ abdominal/back pain, fever, and sepsis

Lower urinary tract symptoms:

-emptying symptoms =

• dysuria, hesitancy, intermittency (interruption of stream while voiding), postvoid dribbling, urinary retention, or incomplete emptying

-storage symptoms =

• incontinence, nocturia, nocturnal enuresis (bedwetting), urgency, urinary frequency

-suprapubic discomfort or pressure, hematuria (blood in urine), cloudy appearance

Upper UTI symptoms:

-fevers, chills, flank pain

Other:

-fatigue, anorexia, asymptomatic

• asymptomatic bacteriuria does not warrant screening or treatment except in pregnant women, those w/ recent kidney transplant, or those having urologic procedure

Older adults:

-common manifestations of a UTI are absent

-general abdominal discomfort, impaired cognition, generalized deterioration, often afebrile

Diagnostics:

-initial: dipstick for nitrates, WBCs, and leukocyte esterase

-urine culture w/ sensitivity

• clean catch urine sample

-Physical and medical hx

• recurring UTIs, complicated UTIs, CAUTIs, HAUTIs, UTIs unresponsive to antibiotics

-Imaging = US or CT scan

UTIs Interprofessional Care

Diagnostic assessment:

-hx and physical exam

-urinalysis, urine for culture and sensitivity

-imaging studies of urinary tract

Uncomplicated management/ drugs:

-patient teaching, adequate fluid intake (8-9, 8oz glasses/day)

-antibiotics

• fluconazole in pts w/ fungal UTIs

• fosfomysin

• nitrofurantoin

• TMP/SMX

• trimethoprim alone (in pts w/ sulfa allergy)

• cephalexin

Recurrent UTI management/ drugs:

-repeat urinalysis, urine culture and sensitivity testing

-adequate fluid intake

-repeat pt teaching, imaging studies of urinary tract

-antibiotic = nitrofuantonin, TMP/ SMX

-sensitivity -guided antibiotic therapy: ampicillin, amoxicillin, 1st or 2nd gen cephalosporin, fluroquinolones

-urinary analgesic s/a phenzopyridine, may relieve discomfort caused by severe dysuria

UTI Nursing management

Health promotion:

-important to recognize people at risk for UTI

• debilitated persons, older adults, patients who are immunocompromised, pts treated w/ immunosuppressive drugs or corticosteroids

-teach preventative measures

• emptying bladder regularly and completely

• evacuating bowel regularly

• wiping perineal area from front to back

• drinking an adequate amount of liquid each day

-routine thorough perineal hygiene important for all hospitalized pts

-prevent CAUTI

• avoid unnecessary catheterization, early removal of indwelling catheters

• aseptic technique during these procedures

• gloves for care of urinary catheters

Acute care:

-ensure adequate fluid intake unless contraindicated

• fluid will increase frequency but also dilute urine, making the bladder less irritable and help flush out bacteria

-avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods or beverages

-apply heat to suprapubic area or lower back

-warm shower or sitting in tub of warm water 

-provide teaching about prescribed drug therapy

-report persistent bothersome LUTS after antibiotics, onset of flank pain, and fever to HCP

Ambulatory care:

-take all antibiotics as prescribed

-practice appropriate hygiene

-empty bladder before and after sexual intercourse

-maintain adequate fluid intake

-avoid vaginal douches and harsh soaps, bubble baths, powders, and sprays in the perineal area

-report signs of recurrent UTI

acute pyleonephritis

inflammation of the renal parenchyma and collecting system, including the renal pelvis

-urosepsis is systemic infection arising from urologic source

-usually begins w/ colonization and infection of lower urinary tract via ascending urethral route

-physiologic changes due to pregnancy in the urinary system is an important risk factor

Manifestations:

-classic: fever/chills, N/V, malaise, flank pain

-dysuria, urgency, frequency

-costovertebral angle tenderness on percussion on affected side

-urosepsis, renal scarring, and decreased kidney function can occur

Diagnostics:

-Urinalysis, Urine cultures w/ sensitivities, US,

-CT scans are preferred imaging studies

Acute pyelonephritis interprofessional care

Diagnostic assessment:

-hx and physical exam

-urinalysis, urine culture and sensitivity, Imaging studies (US, CT, MRI, cystoscopy, voiding cystourethrogram)

-CBC w/ WBC differential, blood culture, percussion for flank pain

Management for Mild symptoms:

-outpatient or short hospitalization

-adequate fluid intake

-NSAIDs, antipyretics

-follow-up cultures and imaging

-antibiotics: oral 5-14 days; IV to oral 14 to 21 days

Management for severe symptoms:

-hospitalization

-adequate fluid intake (IV initially, then oral after N/V subsided)

-NSAIDs or antipyretic drugs

-follow-up urine culture and imaging studies

-combination parenteral antibiotics

Relapses:

-may be treated w/ different course of antibiotics

-6 weeks of antibiotics

-recurrent episodes may receive prophylactic antibiotics

-Urosepsis: monitor for and treat septic shock to prevent irreversible damage or death

Acute pyelonephritis nursing managment

Implementation:

-health promotion and maintenance are similar to those for cystitis

-pts w. structural abnormalities of urinary tract need regular medical care

-emphasize:

• taking antibiotic as prescribed

• having follow-up urine culture

• recognized signs of relapse

-drink at least 8 glasses of fluid everyday even after infection has been treated

-encourage rest

Chronic pyelonepritis

kidneys are continually infected which leads to inflammation and fibrosis (scarring)

-usually result of significant abnormalities s/a vesicoureteral reflux or recurring infections involvng upper urinary tract

-radiologic images can confirm diagnosis and possible contributing factors

-renal biopsy can show loss of functioning nephrons

-can progress to end-stage renal disease

-goal of nursing care is to treat underlying infection and contributing factors and to prevent progression to ESRD

Urethritis

inflammation of the urethra

Causes:

-bacterial or viral infection

-tricomonas, chlamydial infection, mycoplasma, and gonorrhea

• in men cause is usually sexually transmitted = purulent discharge (gonorrheal)

Manifestations:

-LUTS including dysuria, urgency, and frequency

-men may have penile burning

Diagnostics:

-in women may be hard to diagnose

-often produces bothersome LUTS but urethral discharge may not be present

Treatment:

-based on identifying and treating cause and providing symptomatic relief

-TMP/SMX, doxycycline, ceftriaxone, and nitrofurantoin for bacterial infection

-metronidazole and tinidazole for trichomonas

-nystatin, clotrimazole, fluconazole for monilial infections

-doxycycline or azithromycin for chlamydial infections

-warm sits baths

-avoid using deodarant sprays or vaginal gel contraceptives

-cleanse perineal area after bowel movements and voiding

-avoid sexual intercourse for at lest 7 days

• refer sex partners for evaluation if had sexual contact in the 60 days before onset of symptoms or diagnosis

Interstitial cystitis/ painful bladder syndrome (IC/PBS)

IC: chronic, painful, inflammatory disease of the bladder; IC causes PBS

-urgency, frequency, bladder/pelvic pain

-urinary pain not attributed to other causes

Possible causes:

-neurogenic hypersensitivity

-mast cell changes in muscle or mucosal layer

-infection (unusual organism)

-toxic substance in urine

Manifestations:

-primary symptom is pain and bothersome LUTS

• pain usually suprapubic but may involve perineum

• increased pain w/ bladder filling, postponed urination, physical exertion, suprapubic pressure, certain foods, and emotional distress

• decreased pain w/ voiding (temporary)

-severe: void more than 60 times/day-night

-often misdiagnosed as chronic or recurring UTI or chronic prostatitis; diagnosis of exclusion

IC/PBS care

Interprofessional Care:

-nutrition and drug therapies

• reduce intake of bladder irritants

• calcium glycophosphate = med that reduces irritation

-stress management strategies

-tricyclic antidepressants, analgesics, antiistamines

-physical therapy and bladder hypo-distention

-botox; cyclosporine A

-surgery: w/ debilitating pain (sacral neuromodulation or fluguration = using high frequency energy to destroy a lesion)

Nursing management:

-pain assessment

-diet/lifestyle factors that increase or decrease pain

-bladder/voiding log for 3 days; pain record

-monitor for UTI w/ diagnostic studies

-monitor nutrition

-avoid restrictive clothing

-coping strategies/ reassurance

glomerulonephritis

inflammation of the golmeruli; affects both kidneys equally

-glomerulosclerosis in kidney can occur

-can be acute or chronic

• acute (APSGN) = symptoms come on suddenly and may be temporary or reversible

• chronic = progresses slowly and can lead to irreversible renal failure

Acute poststreptococcal glomerulonephritis (APSGN)

common in children aged 5-7 and in adults older than 60

-develops about 1-6 weeks after an infection of the tonsils, pharynx, or skin

Manifestations:

-vary but include generalized edema, HTN, oliguria, hematuria, proteinuria

-red to brown urine occurs w/ bleeding in upper urinary tract

-abdominal or flank pain

-may be asymptomatic

Diagnostics:

-based on complete hx and physical assessment

-dipstick urinalysis and urine sediment microscopy can show significant #s of RBCs

-blood tests including BUN and serum creatinine to assess extent of renal impeirment

Care:

-accurate recognition and assessment are critical

-management focuses on symptom relief

-rest until signs and hypertension subside

-restrict sodium and fluid intake, giving diuretics

-antihypertensive drugs

-restrict protein intake if evidence of increased BUN

-antibiotics if strep infection is still present

-encourage early diagnosis and treatment of sore throats and skin lesions

-take full course of antibiotics

-practice good personal hygiene

Chronic glomerulonephritis

permanent and progressive renal fibrosis involving

-can progress to ESRD

-inherited disorder or autoimmune disorder may be the cause

-often discovered by finding an abnormality on a urinalysis, high BP, or increased serum creatinene

-charcterized by proteinuria, hematuria, and slow development of uremia

-progresses to ESRD over several years

Manifestations:

-varying degrees of hematuria

-proteinuria

-urinary excretion of formed elements including RBCs, WBCs, and casts

-increased BUN and creatinine

Diagnostics:

-US and CT prefered radiologic studies

-renal biopsy

-evaluate pt for other immune disorders s/a SLE

Treatment:

-supportive and symptomatic care

Rapidly progressive golmerulonephritis

-glomerular disease w/ glomerular crescent formations

-characterized by more rapid, progressive loss of renal function over days to months

-3 types = anti-GBM disease, due to immune complex disease, due to pauci-immune disease

Manifestations:

-renal insufficeincy

-hypertension

-edema, hematuria, reduced urine output

Treatment:

-correcting fluid overload, HTN, and uremia

-reduce inflammatory injury to kidney

-corticosteroids and cyclophosphamide

-dialysis or kidney transplant may be considered for the pt w/ RPGN

Nephrotic syndrome

results when golmerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and edema

Causes:

-systemic disease = diabetes, SLE, amyloidosis

-cancers, infections

-drugs = captopril, heroin, lithium, NSAIDs, penicillamine

Manifestations:

-peripheral edema, hyperlipidemia, hypoalbuminemia, and foamy urine are classic manifestations

-ascites and anasarca develop if there is severe hypoalbuminemia

-clacium and skeletal abnormalities may occur = hypocalcemia, hyperparathyroidism, and osetomalacia

-hypercoagulability increases risk for arterial and venous thromboembolis

Care:

-specific treatment depends on cause

-corticosteroids and cyclophosphamide

• prednisone

-managing diabetes is important

-ACE inhibitors, ARBs may reduce protein loss

-Diuretics to improve edema

-lipid-lowering agents

-anticoagulants

-low sodium diet, low-moderate protein diet, small frequent meals

-nursing management focuses on managing edema 

• weigh pt daily

• record I&O

• measure abdominal girth

-avoid exposure to persons w/ unknown infections

obstructive uropathies

any anatomic or functional condition that blocks or impedes the flow of urine

-can be congenital or acuired

-damage occurs above level of obstruction

-severity depends on location, duration, amount of pressure or dilation, presence of urinary statsis or infection

-may affect only one kidney and the other kidney may compensate

Bladder or neck obstruction:

-detrusor muscle hypertrophy

-eventually gets large, residual urine

Bladder outlet obstruction:

-increased pressure w/ filling or storage

-vesicoureteral reflux (backflow), hydroureter (ureter dilation), and hydronephrosis

Parietal obstruction of ureter or uteropelvic junction:

-low to moderate pressure = kidney dilates w/o noticeable loss of functions

-urinary stasis and reflux = increases risk of pyelonephritis

Both kidneys or only 1 functioning kidney involved:

-changes in renal function occur and BUN and creatinine increase

Treatment:

-find and relieve blockage

-insertion of tube, surgery, or urinary diversion

Urinary tract caliculi (stones)

neprolithiasis: kidney stone, renal caliculi

calculus: stone

lithiasis: stone formation

-risk for developing kidney stones increases w/ age

-stone formation occurs most often in summer months, due to contributing factors of hot climate and dehydration

Risk factors:

-climate = warm climates that cause increased fluid loss, low urine level, and increased urine solute concentration

-diet = excess amount of tea or fruit juices, large intake of diet proteins, large intake of salt, low calcium intake, low fluid intake

-genetics = family hx of stone formation, cystinuria, or renal acidosis

-metabolism = abnormalities that result in increased urine pH, calcium, oxalate, or uric acid levels or low citrate

-lifestyle = immobility, obesity, sedentary occupation

5 main types of stones:

-calcium oxalates

-calcium phosphate

-cystine

-struvite

-uric acid 

kidney stone manifestations/ diagnostics

Manifestations:

-first symptom is usually severe pain that begins suddenly

• sharp, severe pain in flank area or back, or lower abdomen = renal colic pain

• results from stretching, dilation, and spasm of ureter in response to obstructing stone

• N/V may occur due to severe pain

-common sites of obstruction are at UPJ and UVJ

• pt may have costovertebral flank pain or renal colic

• intense colicky and can radiate into genital region

-pts w/ renal colic have hard time being still = will go from walking to sitting to lying down then repeat process = “kidney stone dance”

-mild shock w/ cool, moist skin

-men may have tasticular pain while women may have labial pain

-both men and women can have groin pain

-dysuria, fever chills

Diagnostics:

-noncontrast CT or US

-complete urinalysis

-retrival and analysis of stones important in diagnosing underlying problem causing formation

Kidney stone interprofessional care

manage acute attack:

-opioids or NSAIDs for pain

-4mm or less in size can pass spontaneously, however may take few weeks to pass

-alpha adrenergic blockers relax smooth muscles in ureter and can help pass stones

evaluate cause of stone formation and prevent further development:

-family hx; geographic residence; nutrition assessment; fluid intake; vitamins A, C, and D; activity pattern

-hx of prolonged illness, GI or GU disease or surgery, previous stones, prescribed and OTC meds, diet supplements

Treatment and patient teaching:

-adequate hydration

-sodium restriction, diet changes

-drugs = alter pH of urine, prevent excess urinary secretion of a substance, or correct primary disease

-sturitive stones: antibiotics and acetohydroxamic surgery

-endourologic, lithotripsy, or open surgical stone removal may be considered if

• stones are too large (more than 5mm) to pass spontaneously

• are associated w/ bacteriuria or symptomatic infection

• impair renal function

• cause perisitent pain, nausea, or paralytic ileus

• the pt can’t be treated medically or only has one kidney

Kidney stone nursing management

Implementation:

-most people who have had stones can lower risk of recurrence by changing their lifestyle and diet habits

-adequate fluid intake important; output should be around 2.5L/day

• drink 3-4L/da

Nutrition therapy:

-pt should drink adequate fluids to avoid dehydration

• do not force excess fluids as this can increase pain and renal colic

-AFTER episode of kidney stones encourage high fluid intake

• water is preferred fluid

• reduces risk of dehydration

• limit colas, coffee, and tea → increased stone formation

-low sodium diet

-diet restrictions according to type of stone = purine, oxolate, calcium

foods high in calcium

-milk, cheese, ice creae, yogurt, sauces containing milk

-all beans except green beans

-lentils

-fish w/ fine bones = sardines, kippers, herring, salmon

-dried fruits

-nuts

-ovaltine, chocolate, cocoa

*intake should be decreased if cause of calcium kidney stones

foods high in oxalate

-dark roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans

-grapefruuit, orange, raspberries

-chocolate, cocoa, instant coffee, ovaltine, tea

-worcestershire sauce

*intake should be decreased if diagnosed w/ oxalate kidney stone

foods high in purine

-sardines, anchovies, herring, mussles, scallops, organ meats, kidney, goose

-chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham

*intake should be decreased if diagnosed w/ purine kidney stone

Endourologic procedures

-cystoscopy: remove stone in bladder

-Cstolitholapaxy: large stones broken up w/ lithotrine (stone crusher)

-cystoscopic lithotripsy: ultrasonic waves break stones

*complications of above procedures = hemorrhage, retained stone fragments, and infection

-ultrasonic laser or electrohydraulic lithotripsy: used to break stones during

• flexible ureteroscopes = remove stones from renal pelvis and upper urinary tract

• percutaneous nephrolithotomy = nephroscope inserted through skin into pelvis of kidney; stone fragmented and removed, followed by irrigation. may place nepghrostomy tube

*complications = bleeding, injury to adjacent structures, and infection

Lithotripsy

procedure to eliminate stones from the urinary tract

• laser lithotripsy:

• extracorporeal shock-wave lithotripsy:

• percutaneous ultrasonic lithotripsy:

• electrohydraulic lithotripsy:

-ureteral stent placed to facilitate passage of sand; removed in 2 weeks

• post procedure: hematuria; prophylactic antibiotic use

• encourage fluids to dilute urine and reduce pain

-complications (rare): hemorrhage, infection, obstruction

Kidney stone surgical therapy

Primary indications for surgery: pain, infection, obstruction

-Type of surgery depends on location of stone

• nepholithotomy: kidney

• pyelolithotomy: renal pelvis

• ureterolithotomy: ureter

• cystotomy: bladder

-post-op complication: hemorrhage

ureteral strictures

narrowing of the lumen of the ureter or urethra

-can affect the entire length of the ureter, from the UPJ to UVJ

-can affect kidney function

Manifestations:

-mild to moderate colic, flank pain, and CVA tenderness

-pain may be moderate to severe in intensity

Treatments:

-obstruction may be temporarily bypassed by placing a stent using endoscopy or by dverting urine flow through a nephrostomy tube

-endeureterotomy

-ureterourterostomy = y shaped drain

-ureteroneocystostomy = ureter attached directly to bladder

Causes:

-trauma, urethritis, surgical intervention or repeated catheterizations, congenital defect, idiopathic

Urethral strictures

the result of fibrosis or inflammation of the urethral lumen

Causes:

-trauma, urethritis, surgical interventions, repreated catheterizations, congenital defects of urethra

-meatal stenosis = a narrowing of the urethral opening at the tip of the penis

Manifestations:

-diminished force of urinary stream

-sprayed stream

-postvoid dribbling

-split urine stream

-feelings of incomplete bladder emptying, urinary frqenucy, nocturia

Treatment:

-dilation w/ meatal instruments or stents of increasing size; stenosis may occur

-slef-catheterization every few days

-endoscopic or surgical procedure

• urethroplasty

• resection and re-anastomosis of urethra

renal trauma

can be bunt or penetrating

-injury to the kidney can occur w/ sports, injuries, MVAs, and falls

-penetrating injuries may result from violent encounters = gunshot, stabbing

Manifestations:

-gross or microscopic hematuria may be present

Diagnostics:

-contast enhanced CT and CT pyelography

-both involved and uninvolved kidney may need to be evaluated

Nursing care:

-depends on type of trauma and the extent of any associated injuries

-asses cardiovascular status and monitor for shock

-ensure adequate fluid intake and monitor I&O

-provide for pain relief

-assess for hematuria and myoglobinuria

-evaluate pt and vital signs frequently

Polycystic kidney disease

genetic disorder = cysts form in the kidneys that can cause the kidneys to change shape and enlarge over time

-2 heriditary forms usually diagnosed in early childhodd and the other in adulthodd

• adult PKD (APKD) involves both kidneys = autosomal dominant

• childhood = autosomal recessive

APKD:

-can be asymptomatic for years; S/sx develop btwn 30-50 years of age

• often 1st manifeststaion is HTN, hematuria, proteinuria, loss of kidney function, and/or feeling of pain or heaviness in the side, back, or abdomen

• most common problem is chronic severe pain

-acute pain can develop from kidney stone formation, UTIs, cyst hemorrhage

• pain can be constant and severe

• bilateral enlarged kidneys often palpable

-can affect liver, pancreas, heart, blood vessels, and intestines

-most serious complication is cerbral aneurysm which can rupture

Diagnostics:

-manifestations, family hx, US, or CT scan'

Treatment:

-NO CURE

-prevent or treat UTI, nephrectomy, dialysis and kidney transplant

-Nursing: management of ESRD; genetic counseling

Kidney cancer

renal cell carcinoma (adenocarcinoma) = most common

-affects males more than females; avg age 64 years old

Risk factors: 

-cigarette smoking, ACKD, obesity, HTN, exposure to asbestos/cadmium/gasoline

-increased incidence if first-degree relative hx

Manifestations:

-early stage = asymptomatic; often incidental finding for unrelated condition

• 25% have metastasis when diagnosed = → renal vein, vena cava, lungs, liver, and long bones

-common manifestations:

• hematuria, flank pain

• weight loss, fever, anemia, fatigue, hypercalcemia, and/or palpable mass in flank or abdomen

Diagnostics:

-CT scan, US, angiography, biopsy, MRI; radionuclide isotope scan

Kidney cancer stages

I: the tumor can be up to 7cm in diameter and is confined to the kidneys

II: tumor is larger than in stage 1 but still confined to kidneys

III: tumor extends beyond kidney to surrounding tissue. Has not spread to adrenal gland or to Gerota fascia

IV: cancer spreads outside kidney beyond Gerota fascia . Can involve multiple lymph nodes or spread to distant sites = bones, brain, liver, lungs

Kidney cancer care

Preventions:

-quit smoking

-main tain healthy weight

-control BP

-avoid exposure to toxins

-identify-high risk groups

-pt teaching of early manifestations

Treatments:

-treatment of choice for some kidney cancers is a partial neprectocmy, simple total nephrectomy, or radical nephrectomy

-cryoablation

-radiofrequency ablation

-kidney cancer is relatuvely resistant to most chemo therapy drugs

Bladder cancer

most common cancer of the urinary system

-affects men more than women; whites more than blacks and hispanics

-trasitional cell cancer = most frequent; most are papillomatous growths

Risk factors:

-cigarette smoking

-industial exposure to dyes; cervical cancer treated w/ radiation or chemotherapy; prolonged indwelling catheters; chronic recurrent stones; chronic UTIs

Manifestations:

-most common = microscopic or gross, painless hematuria

-dysuria, frequency, and urgency

Diagnostics:

-urine specimens for cancer or atypical cells, and bladder tumor antigens

-CT scan, US, or MRI

-cystoscopy and biopsy = confirm cancer

Treatments: surgery, radiation, chemotherapy, intrevesical therapy

Bladder cancer staging

I: cancer is in the inner lining of the bladder but has not spread to bladder muscle wall

II: cancer is in inner lining of the bladder wall but is still confined to the bladder

III: cancer has spread through the bladder wall to surrounding tissue

IV: cancer has spread to bowels, prostate, vagina, and/or uterus

Transurethral resection of bladder tumor (TURBT)

superficial lesions removed w/ cystoscope

-fulguration (burns base of tumor) or high enerygy laser (kills cancer cells)

-used to control bleeding in high risk pts or w/ advanced tumors

-disadvantage: re-occurence, scarring, or inability to hold urine (repeated TURBTs)

Cystectomy (bladder cancer)

segmental (partial) cystectomy:

-remove large tumors in 1 area of bladder wall and margin of normal tissue

Radical cystectomy:

-invasive tumors or trigone area but no metastasis beyond pelvic area

-must have urinary diversion

-men = bladder, prostate, and seminal vesicles

-women = bladder, ueterus, cervix, urethra, anterior vagina, and ovaries

Post-op care:

-drink large volume of fluid for 1 week

-monitor color and consistency of urine

• pink for several days; not bright red or w/ clots

• may have dark red or rust-colored flecks for 7-10 days

-opioid analgesics and stool softeners

-coping

-follow-up care = regular cystoscopies

Radiation and Chemotherapy (Bladder cancer)

Radiation:

-primary therapy or in combo w/ cystectomy

Immunotherapy:

-local instillation of immunotherapy or chemotherapy by urethral catheter

• retained for 2 hours; change position every 15 minutes

• weekly intervals for 6-12 weeks

• induction and maintenance therapy

• post procedure: irritative voiding and hemorrhagic cystitis = increase fluids

Urinary incontinence (UI)

involuntary leakage of urine

-NOT a natural consequence of aging 

Risk factors:

-obesity, BPH, smoking, recurrent UTIs, GI surgeries

-vaginal delivery, impaired functional status, certain neruologic problems

-family hx

Gender differences:

-men = common w/ BPH or prostate cancer; overflow incontinence from urinary retention

-women = stress and urge incontinence

Patho:

-DRIP

• D = delerium, dehydration, depression

• R = restricted mobility, rectal impaction

• I = infection, inflammation, impaction

• P= polyuria, polypharmacy

Types of incontinence:

-stress

-urge

-overflow

-reflex

-incontinence after trauma or surgery

-functional incontinence

*may have more than one type

Diagnostics

-basic evaluation

• bladder log or voiding record for 1-7days

• onset, provoking factors, and associated contions

-physical exam

• general health and functional issues

• pelvic exam

-urinalysis, postvoid residual, urodynamic studies, US

UI care

Interprofessional care:

-transient, reversible factors are first corrected, fowllowed by management of the type of UI

-individualized to pt preferrence, type and severity, and anatomic defects

• lifestyle modifications

• schedule voding regimens

• pelvic floor muscle rehab

• antiincontinence devices

• containment devices

Drug therapy:

-anticholinergics

Surgical therpay:

-urinary structural support/ repositioning

-increased urethral resistance of internalsphincter and intraabdominal pressure reception

-retropubic colpssuspension and pubovaginal sling

-suburethral sling

-bulking agent injection

-artificial sphincter surgery (cuff placed around urethra)

Nursing management:

-identify physical and emotional concerns

-maintain dignity, privacy, and self-worth

-2 step approach

• containment devices for urinary leakage

• plan to reduce or resolve UI factors

-life style modifications, behavioral treatments, products to contain urine

Urinary retention

inability to empty the bladder when a person voids OR the accumulation of urine in the bladder bc of inability to void

-Acute: inability to pass urine via micturition = medical emergency

-Chronic: incomplete bladder emptying despite urination

-normal PVR is 50mL; a PVR over 200mL is abnormal

Causes:

-neurologic impairment, bladder outlet obstruction, deficient detrusor contraction strength

-common cause of obstruction in men is enlarged prostate

Diagnostics:

-PVR measurement, urodynamic evaluation, video urodynamic evaluation, cystourethroscopy, and electromyography

Urinary retention care

Interprofessional care:

-Behavioral therapies

• schedule toileting and double voiding

-Catheterization may be needed = intermittent or indwelling

-Drug therapy

• alpa adrenergic blockers = relax the smooth muscle of the bladder neck and prostatic urethra and may decrease urethral resistance

Surgical therapy:

-transurethral or open techniques for

• prostate enlargement or cancer

• bladder neck contracture

• urethral strictures

• dyssynergia of bladder neck

-abdominal or transvaginal approach for pelvic organ prolapse

-surgical therapy for deficient detrusor contraction

• sacral neuromodulation = stimulation to bowel and bladder

• intraurethral valve pump = external device that activates bladder

Nursing management:

-acute urinary retention is a medical emergeny that requires prompt bladder drainage

• insert catheter; consider indwelling

• pt teaching to minimize risk = drink small amount throughout the day; be warm when trying to void; avoid excess alcohol

• if unable to void drink ceffeinated coffee or tea to increase urgency; warm bath/shower; seek medical care

-chronic urinary retention may be managed w/ behavioral methods, indwelling or intemittent catheterization, surgery, or drugs

• schedule toileting and double voding

• void every 3-4 hrs regardless of desire to void

Indications for catheterization

Indications for indwelling:

-relief of urinary retention

-bladder decompression preop or postop

-faciliatate surgery

-faciliatate healing

-accurate I&O = critical care

-stage III or IV pressure ulcer

-terminal illness = comfort

Indications for intermittent:

-relief if urinary retntion

-diagnostic study

-urodynamic testing

-sterile specimen

-medication instillation

-measure PVR

Unacceptable reasons:

-routine urine specimen

-conveinance for nurse or pts family

Complications of long-term use (more than 30 days)

-CAUTI = most common HAUTI

-bladder spams, periurtehral abscess, chronic pyelonephritis, urosepsis, urethral taruma or erosion, fistula formation, and stones

Ureteral catheters (stents)

placed through ureter into renal pelvis by

• threading urethra and bladder w/ cystoscopy

• surgical insertion through abdominal wall into ureters

-used post-op to prevent obstruction by edema

-record ouptu seperately for urethral catheter

-bed rest

-check placement; avoid tension; do not clamp

-aseptic technique w/ irrigation

-monitor output every 1-2hrs

• renal pelvis holds 3-5mL; increased volume can cause tissue damage

Suprapubic catheters

form of urinary diversion; may be temporary or long term

-insertion is either through abdominal wall or using trocar; general or local anesthesia used; may be sutured. Tape to prevent dislodgement

-care similar to urethral catheter; use skin barrier to protect skin at insertion site

-ensure patency: prevent kinking, turn pt side to side, milk tube, or irrigate (w/ order) using sterile technique

-bladder spams = antispasmodics

Nephrostomy tubes

temporary insertion through small flank incision into renal pelvis to preserve renal function when ureter completely obstructed; attached to drainage bag

-avoid kinking, compression, or clamping

-check patency if pt has ecessive pain or drainage around the tube

-strict aseptic technique if irrigation orderd; no more than 5mL sterild NSS

-complications: infection and secondary stone formation

Intermittent catheterization

“straight” or “in-and-out”

-main goal: prevent urinary retention, stasis and compromised blood supply to the bladder from prolonged presure

-used w/ = neurogenic bladder, bladder obstruction in men, or post-op to treat UI

-catheter inserted every 3-5hrs or 1-2x/day for residual urine to ensure an empty bladder

Variable techniques and protocols:

-sterile (single use) or clean (multiple use)

-coated or uncoated

-inserted by pt, caregiver, or HCP

-need prophylactic antibiotics

complications: urethritis, urethral sphincter damage, urethral stricture, creation of a false passage

Renal and ureteral surgery

indications for nephrectomy = renal tumor, bleeding ot infected plycystic kidneys, massive taruma, or donor transplant

-surgical procdures : open or laproscopic

• open: 6-10 inch incision in flank or abdomen

• laproscopic = 3-5 puncture sites

-surgery to ureters and kidneys = remove obstructing stone, congeintal abnormalities, and urinary diversion

Pre-op:

-ensure adequate fluid and normal electrolytes

-may have pain from positioning in OR

Post-op:

-urine output meausre and record every 1-2hrs

-total output should be 0.5ml/kg/kr

-check dressings

-note color and cosistency; catheter patency

-daily weights

-respiratory status

• nephrectomy flank incision painful = administer analgesia so pt can participate in turning, coughing, and deep breathingm incentive spirometry, and early/frquent ambulation

-abdominal distention

• monitor for paralytic ileus, IV fluids when bowel sounds return, progress to regular diet

Urinary diversion

urine flow blocked from

• bladder cancer, neurogenic bladder, congeital anomalies, strictures, bladder trauma, and chronic bladder inflammation

• types of surgical procedures for urinary diversion

Nursing management:

Incontinent Urinary deiversion

diversion to skin; must wear appliance

-most common = ileal conduit (ileal loop); colon conduit also used

-ureters anastomosed to conduit; bowel brought to abdominal wall to form stoma

-no valve = no voluntary control

-urine drips into external collection device

Continent urinary diversion

intrabdominal urinary reservoir that can be catheterized; has internal pouch

-reservoirs constructed from ileum, ileocecal segment, or ascending colon

-surgically created valve and large, low pressure reservoir prevent involuntary leakage; no external collection device

-pt self-cathterizes every 4-6hrs

orthotopic bladder reconstruction

construction of a new bladder in correct anatomical position = urine discharged through urethra

-neobladder surgically shaped from various segments of intesines; distal ileum common; urteters and urethra sutured to neobladder

-candidates: normal renal and liver function; 1-2yr life expecteancy; adequate motor skills; no IBD or colon cancer; not obese

-ex: hemi-kock, studer pouch, and W-shaped ileoneobladder

-incontinence may occur; may need intermittent catheterization

Kidney failure

aka renal failure

-inability tp excrete metabolic waste products and water

-pts have problems w/ fluid, electrolyte, and acid-base balance

-classified as acute or chronic

• acute has rapid onset

• chronic is gradual w/ a progressive decline in kidney function

AKI vs. CKD

AKI:

-onset is sudden

-most common cause is acute tubular necrosis

-diagnostic criteria: acute reduction in urine output AND/OR ↑serum cretinine

-poteintailly reversib;e

-mian cause of death is infection

CKD:

-onset is gradual, often over many years

-most common cause is diabetic neuropathy

-diagnostic criteria: GFR<60mL/min/1.73 for over 3 months AND/OR kidney damage longer than 3 months

-progressive and irreversible

-main cause of death CVD

Acute kidney injury (AKI)

ranges from slight deterioration in kidney function to severe impairment

-rapid loss of kidney function w/ or w/o decreased urine output

-progressive increases in blood urea nitrogen (BUN), creatinine, and potassium. Cna lead to azotemia

-can develop over hours or days and has hig mortality rate

-often follows severe, prolonged hypotension, hypovolemia, or exposure to a nephrotoxic agent

-causes are characterized as…

• prerenal = factors that reduced systemic circulation leading to decreased renal blood flow

• intrarenal = problems that cause direct damage to kidney tissue, resulting in impaired nephron function

• postrenal = involve mechanical obstruction in outflow of urine → urine refluxes into renal pelvis, impairing kidney function

azotemia

accumulation of nitrogenous waste products (urea nitrogen, creatinine) in the blood

prerenal causes (AKI)

-Decreased cardiac output = cardiogenic shock, dysrhythmias, HF, MI

-Decreased periheral vascular resistance = anaphylaxis, neurologic injury, septic shock

-Decreased renovascular blood flow = bilateral renal vein thrombosis, embolism, hepatorenal syndrome, renal artery thrombosis

-Hypovolemia = burns, dehydration, excessive diuresis, GI losses (diarrhea, vomiting), hemorrhage, hypoalbuminemia

-decrease in blood flow leads to decreased glomerurlar perfusion and filtration by the kidneys

-prerenal oliguria there is no damage to the kidney tissue

• oliguria is caused by a decrease in circulating volume

• readily reversible w/ proper treatment

-prerenal azotemia results in decreased sodium and water retention, and decreased urine output

-if decreased perfusion persists for an extended amount of time, the kidneys loose their ability to compensate and damage to kidney tissue occurs

Intrarenal causes (AKI)

-Interstitial nephritis

• allergies: antibiotics, NSAIDs, ACE inhibitors

• infections: bacterial, viral, fungal

-Nephrotoxic injury

• chemical exposure: ethylene glycol, lead, arsenic, carbon tetracholride

• contrast media

• drugs: aminoglycosides, amphotericin B

• hemolytic blood transfusion reaction

• severe crush injury

-Other

• acute glomerulonephritis, malignant hypertension, prolonged prerenal ischemia, SLE, thrombotic disorders, toxemia of pregnancy

-acute tubular necrosis (ATN) is the most common intrarenal cause of AKI in hospitalized pts

• can result from ischemia, nephrotoxins, or sepsis

• other risk factors include major surgery, shock, blood transfusion reaction, muscle injury from trauma, and prolonged hypotension

Postrenal causes (AKI)

-BPH, bladder cancer, calculi fomration, neuromuscular disorders, prostate cancer, spinal cord disease, strictures, trauma (back, pelvis, perineum)

-if bilateral obstruction is relived w/i 48hrs of onset, complete recovery is likely

-prolonged obstruction can lead to tubular atrophy and irreversible kidney fibrosis

AKI manifestations

may progress through phases = oliguric, diuretic, and recovery

-when pt does not recover CKD may develop

-RIFLE classification describes stages of AKI

-Risk

• serum creatinine increased 1.5x OR GFR decreased by 25%

• urine output <0.5mL/kg/hr for 6hr

-Injury

• serum creatinine increased 2x OR GFR decreased by 50%

• urine output <0.5mL/kg/hr for 12hrs

-Failure

• serum creatinine increased 3x OR GFR decreased by 75% OR serum creatinine >4mg/dL w/ acute rise >0.5mg/dL

• urine output <0.3mL/kg/hr for 24hr (oliguria) OR anuria 12hr

-Loss

• persistent acute kidney failure. Complete loss of kidney function >4 weeks

-Endstage renal disease

• complete loss of kidney function >3 months

Oliguric phase (AKI)

Urinary changes:

-most common initial manifestation is oliguria

• urine output less than 400mL/day; occurs w/i 1-7 days

• lasts on average 10-14 days; can last months in some cases

-nonoliguric AKI has urine output greater than 400mL/day

-anuria is usually seen w/ urinary tract obstruction

-urinalysis may show casts, RBCs, and WBCs

-proteinuria may be present if AKI is related to glomerular membrane dysfunction

Fluid Volume:

-hypovolemia has the potential to worsen all forms of AKI

-neck veins may become distended w/ a bounding pulse

-edema

-hypertension

-HF, pulmonary edema, pericardial and pleural effusions

Metabolic Acidosis:

-pt w/ severe rapid acidosis may develop rapid, deep, respirations to try to compensate by increasing CO2 exhalation = Kussmaul respirations

Sodium Balance:

-sodium excretion may increase resulting in normal or below normal levels of sodium

-excess sodium intake is avoided 

-uncontrolled hyponatremia or water excess can lead to cerebral edema 

Potassium excess:

-risk for hyperkalemia increases if AKI caused by massive tissue trauma

-metabolic acidosis worsens hyperkalemia

-often asymptomatic, may have weakness and ECG changes

-emergency treatment of hyperkalemia is needed

Hematologic problems:

-leukocytosis is often present. Most common cause of death in AKI is infection

Waste product accumulation:

-BUN and serum creatinine levels are increased

• increased BUN can also be caused by dehydration, corticosteroids, catabolism so best indicator of AKI is creatinine

Neurologic problems:

-fatigue, difficulty concentrating, seizures, stupor, coma

Diuretic phase

-daily urine output is usually around 1-3L and may reach 5L

-kidneys have recovered their ability to excrete wastes but not to concentrate urine

-hypovolemia and hypotension can occur from massive fluid losses

-large losses of fluid and electrolytes require us to monitor for hyponatremia, hypokalemia, and dehydration

-phase may last 1-3 weeks

-near end of phase acid-base, electrolyte, BUN, and creatinine values stabilize

Recovery phase

begins when the GFR increases

-BUN and serum creatinine levels continue to decrease

-may take 12 months for kidney function to stabilize

-some pts do not recover and progress to ESRD

AKI diagnostics

-thorough hx

-serum creatinine, BUN, electrolytes

-urinalysis (sediment/cast/protein)

-renal ultrasound (looking for nephrotoxicity)

-renal scan (assess for kidney blood flow and tubular function)

-CT scan (assess for lesions/masses/obstructions)

-renal biopsy (best way to determine intrarenal causes)

-contarindications for contrast medium

• MRI or MRA w/ gadolinium contrast medium = may be fatal

• nephrogenic systemic fibrosis

• contrast induced-nephropathy (CIN)

AKI interprofessional care

main goals of treatment are to eliminate the cause, manage the s/sx, and prevent complications while the kidneys recover

-diuretic therapy may be given

• closely monitor fluid intake during oliguric phase

• fluid restriction calculation: all fluid for previous 24hrs + 600mL

-conservative therapy may be all that is necessary until kidney function improves.

-if conservative therapy not effective → RRT (renal replacement therapy). Indications include

• volume overload

• elevated serum potassium level

• metabolic acidosis

• BUN level >120 mg/dL (43 mmol/L)

• significant change in mental status

• pericarditis, pericardial effusion, or cardiac tamponade

• clinical status of pt

-peritoneal dialysis, hemodialysis, continuous renal replacement therapy

-hemodialysis is method of choice when changes are needed emergently

Nutrition Therapy:

-maintain adequate caloric intake

• primarily carbohydrates and fats

• adequate protein to prevent breakdown

-restrict sodium, potassium, and phosphate

-increase fat

-enteral/parenteral nutrition

Treatment for Hyperkalemia (AKI)

-Regular IV insulin

-Sodium bcarbonate

-Calcium gluconate IV

-Sodium polyesteren sulfonate (Kayexalate)

-Patiromer (veltassa) and Sodium Zirconium Cyclosilicate (SZC)

-Hemodialysis

-Diet restriction

Nursing management of AKI

Assessment:

-daily weights

-strict I&Os

-vital signs

-assess urine for color, specific gravity, glucose protein, blood, and sediment

-edema, neck vein distention, or bruises

-if receiving dialysis assess site for inflammation and exudate

-assess mental status and LOC

-auscultate lungs for crackles, wheezes or decreased breath sounds

-assess ECG for dysrhythmias

Implementation:

-identify and monitor high-risk populations

• control exposure to nephrotoxic drugs and industrial chemicals

• prevent prolonged episodes of hypotension and hypovolemia

-monitor weight, I&O, and fluid an electrolyte balance

-prompt replacement of significant fluid losses

-aggressive diuretic therapy

-use nephrotoxic drugs sparingly;

• NSAIDs may worsen kidney function

• ACE inhibitors may need to be reduced or stopped (cause hyperkalemia)

Acute Care:

-manage fluid and electrolyte balance during oliguric and diuretic phases

-assess for s/sx of hypervolemia or hypovolemia, potassium and sodium problems, and other electrolyte imbalances

-aseptic technique is critical to protect pt from infections

-perform good skin care to prevent pressure injuries as mobility may be impaired

Ambulatory care:

-regular evaluation of kidney function

-teach s/sx of recurrent kidney disease

-make appropriate referrals for counseling

Gerontologic considerations (AKI)

-decreased GFR w/ aging

-more susceptible to AKI

• dehydration due to polypharmacy, acute febrile illness, and immobility

-other common causes = hypotension, diuretic therapy, aminoglycoside therapy, obstructive disorders, surgery, infection, and contrast media

-reduced ability to recover

-RRT still an option

Chronic kidney disease (CKD)

progressive, irreversible loss of kidney function

-mush more common than AKI

Risk factors:

-age > 60 ears

-cardiovascular disease

-diabetes

-ethnic minority = black, native american

-exposure to nephrotoxic drugs

-family hx of CKD

-hypertension

Patho:

-often asymptomatic = underdiagnosed and untreated

-leading causes are diabetes and hypertension

• other causes include glomerulonephritis, cystic disease, and urologic diseases

-defined by KDIGO as 

• presence of kidney damage OR

• GFR < 60mL/min/1.73m for longer than 3 months

-ESRD occurs when GFR is less than 15mL/min

• RRT is needed to maintain life at this point

Stages of CKD

Stage 1:

-kidney damage w/ normal or increased GFR

-GFR > 90

-clinical action plan: diagnosis and treatment; CVD risk reduction; slow progression

Stage 2:

-kidney damage w/ mild dcreased GFR

-GFR = 60-89

-clinical action plan: estimation of progression

Stage 3A:

-moderate decrease in GFR

-GFR = 45-59

-clinical action plan: evaluation and treatment of complications

Stage 3B:

-moderate decrease in GFR

-GFR 30-44

-clinical action plan: more aggressive treatment of complications

Stage 4:

-severe decrease in GFR

-GFR = 15-29

-clinical action plan: preparartion for RRT (dialysis, kidney transplant)

Stage 5:

-kidney failure

-GFR = <15 or dialysis

-clinical action plan: RRT (if uremia present and patient desires treatment)

CKD manifestations

manifestations result from retained urea. creatinine, phenols, hormones, electrolytes, and water

-uremia = kidney function declines to a point that symptoms may develop in multiple body systems = occurs when GFR is 15mL/min or less

Urinary system:

-in early stages do not usually report change in urine output

-polyuria may be present

-as disease progresses have problems w/ fluid retention and need diuretic therapy

-may develop anuria

Metabolic disturbances:

-BUN and serum creatinine levels increase

• serum creatinine clearance determinations are more accurate indicators of kidney function than BUN or creatinine

• may contribute to N?V, lethargy, fatigue, impaired cognition, and headaches

-mild to moderate hyperglycemia and hyperinsulemia may occur

• pts w/ diabetes may need less insulin

-many pts develop dyslipidemia w/ ↑VLDLs, ↑LDLs, and ↓HDLs

Electrolyte and acid-base imbalances:

-hyperkalemia that can lead to fatal dysrhythmias

• results from kidney excreting less potassium, the breakdown of cellular protein, bleeding, and metabolic acidosis

-sodium may be high, normal, or low

• retention can contribute to edema, hypertension, and HF

-hypermagnesemia can cause absent reflexes, decreased mental status, dysrhythmias, and hypotension

-metabolic acidosis results from the kidney’s impaired ability to excrete excess acid and from defective reabsorption and regeneration of HCO3

CKD manifestations (2)

Hematologic system:

-anemia due to decreased erythropoietin production can occur

• many pts are iron deficient and need iron supplementation

• many pts receive folic acid supplements

-most common cause of bleeding in uremia is defect in platelet function

-advanced CKD has increased risk of infection

Cardiovascular system:

-most common cause of death in CKD is CVD

• MI, ischemic heart disease, peripheral arterial disease, HF, cardiomyopathy, and stroke

• CVD may be associated w/ vascular calcification and arterial stiffness

-hypertension is both a cause and consequence of CKD

• BP control one of the most important therapeutic goals in CKD management

Respiratory system:

-Kussumal breathing related to acidosis

-dyspnea may occur w/ = fluid overload, pulmonary edema, uremic pleuritis, pleural effusions, respiratory infections

GI system:

-stomatitis w/ exudates and ulcerations, a mettalic taste in the mouth, peridontal disease, and uremic fetor (urinous odor of the breath) often occur in CKD

-anorexia, N/V, wieght loss, malnutrition

-GI bleeding is a risk bc of mucosal irritation and platelet defect

-Constipation

CKD manifestations (3)

Neurologic system:

-CNS becomes depressed

• lethargy, apathy, decreased ability to concentrate, fatigue, irritability, altered mental ability

-seizures and coma may result from rapidly decreaseing BUN and hypertensive encephalopathy

-may may parasthesia in the feet and legs

-bilateral foot drop, muscular weakness and atrophy, and loss of DTR

-muscle twitching, jerking, asterixis (hand-flapping temor), and night time leg cramps

-advanced stage 5 CKD may develop restless leg syndrome

-treatment of neurologic problems is dialysis or a transplant

Musculoskeltal system:

-CKD mineral and bone disease develops as systemic disorder caused by progressive deterioration of kidney function

• skeletal complications s/a ostomalacia, osteitis fibrosis

• soft tissue complications s/a vascular calcifications

• higher risk for fractures

-gold standard for diagnosis is bone biopsy

Skin:

-refractory itching is more common in pts receiving dialysis

• can be so intense that it leads to bleeding or infection from scratching

-uremic frost = urea crystallizes on the skin

• usually seen only when BUN levels are very high

Reproductive system:

-both women and men have infertility and dcreased libido

-sexual function may improve w/ maintenance dialysis and become normal after a successful transplant

-pregnancy during dialysis poses a significant risk to mother an infant

CKD diagnostics

overall goals are to prserve existing kidney function, reduce risks of CV disease, prevent complications, and provide for pts comfort

-early recognition and treatment important

-when pt has CKD therapy is aimed at treating CVD plus slowing the progression of kidney disease

-focus during stages 1-4 includes controlling BP, hyperparathyroidism, CKD-MB, anemia, and dyslipidemia

Drug therapy:

-Hyperkalemia

• restrict high potassium foods

• sodium polyesterene sulfonate; Patiromer (veltassa);

-Hypertension

• weight loss, lifestyle changes, diet recommendations, antihypertensive drugs

• ACE inhibitors and ARBs given to pts w/ diabetes and those w/ nondiabetic proteinuria

-CKD-MB

• limiting phosphorus intake, giving phosphate binders, supplementing vitamin D, and controlling hyperparathyroidism

• calcium acetate and calcium carbonate = bind phospahte in bowel and excrete it in the stool. Should be administered w/ each meal

• avoid aluminum and magnesium preparations

• chloecalciferol; serum phosphate level must be lowered before calcium or vitamin D is adminsitered

• calcimimetic agents = cinacalcet. Increase the sensitivity of calcium receptors in the parathyroid glands

• subtotal or total parathyroidectomy

-Anemia:

• exogenous erythropoietin = epoetin alfa (Epogen, Procrit), Darbepoetin alfa (Aranesp). Given IV or sub-q. Increased Hbg and Hct in 2-3 weeks. 

• iron supplements 

• supplemental folic acid

-Dyslipidemia

• statins = atrovastatin

• fibrates = gemfibrozil

-Complications: CKD causes decreased elimination that leads to accumulation of drugs and potential for drug toxicity 

• digoxin, diabetic agents (metformin, glyburide), antibiotics, and opioid drugs

CKD nutritional therapy

-designed to maintain good nutrition; monitor lab parameters

-protein intake is normal for HD pts and increased for PD pts

-fluid restriction w/ HD; intake depends on daily urine output

-restrict sodium

• avoid high sodium foods s/a processed meats, canned soups and stews, cold cuts, and many dressings

• pts on HD should avoid foods high in potassium; PD pts do not usually need potassium restrictions

-phosphate restriction in ESRD

• foods that are high in phosphate include meat and dairy products

• many foods high in phosphate are also high in protein

Nursing management CKD

Asessment:

-complete hx of any kidney disease or family hx of kidney disease

-medication hx

• decongestants and antihistamines can cause vasoconstriction and lead to increase in BP

• NSAIDs contribute to the development of AKI and progression of CKD

-assess diet habits

-measure height and weight

Implementation:

-identify those at risk = diagnosed w/ diabetes or hypertension and people w/ personal or family hx of kidney disease or repeated UTI

-monitor kidney function w/ serum creatinine, BUN, and GFR

-glycemic control for pts w/ diabetes; BP control; lifestyle modifications including smoking cessation

Acute care:

-most care of CKD clients occurs in outpatient settings

-hospital care is needed for management of complications or kidney transplant

Ambulatory care:

-teach pt and caregiver about diet, drugs, and follow-up care

-avoid OTC drugs s/a NSAIDs and aluminum- and magnesium-based laxatives and antacids

-take daily BP readings

-watch for s/sx of fluid overload, hyperkalemia, and other electrolyte imbalances

-transplant offers best outcome for ESRD pts

-most pts need either PD or HD

• even while on dialysis transplant is still an option

-discuss palliative care as needed

Dialysis

the movement of fluid and molecules across semipermeable membrane from one compartment to another

-corrects fluid and electrolyte imbalances and removes waste products in kidney failure

-can also be used to treat drug overdoses

-2 methods = peritoneal dialysis (PD) and hemodialysis (HD)

• in PD peritoneal membrane acts as semipermeable membrane

• in HD an artificial membrane is used as semipermeable membrane and is in contact w/ pts blood

-started when GFR is < 15mL

certain uremic complications s/a encephalopathy, neuropathies, hyperkalemia, pericarditis, and accelerated hypertension, indicate need for immediate dialysis

-ESRD pts treated w/ dialysis bc

• lack of donated organs

• physically or mentally unsuitable for transplants

• do not want transplants

-pts age is not a factor in determining candidacy for dialysis

Principles of Dialysis

diffusion, osmosis, and ultrafiltration is involved

-diffusion: movement of solutes from an area of high concentration to an area of low concentration

• in kidney failure, urea, creatinine, uric acid, and electrolytes move from the blood to the dialysate w/ the net effect of lowering their concentration in the blood

-osmosis: the movement of fluid from an area of lower concentration to an area of high concentration

• glucose in the dialysate creates an osmotic gradient across the membrane, pulling excess fluid from the blood

-ultrafiltration (water and fluid removal): results when there is an osmotic gradient or pressure gradient across the membrane

Peritoneal Dialysis (PD)

Catheter placement:

-obtained by inserting a catheter through the anterior abdominal wall

-catheter has 1 or 2 Dacron cuffs

• cuffs act as anchors and prevent microorganisms into the peritoneum

-tip of catheter rests in peritoneal cavity

• pt prep for insertion includes emptying the bladder nd bowel, weighing the pt, and obtaining signed consent

-PD may be started at once or delayed for 2 weeks pending healing and sealing of site

-critical to maintain aseptic technique to avoid peritonitis

Solutions and Cycles:

-done by putting dialysis solution into peritoneal space

-3 phases: inflow (fill), dwell (equilibrium), and drain = exchange

• during inflow a prescribed amount of solution is infused

• during dwell phase diffusion and osmosis occur btwn the pts blood and peritoneal cavity

• draining phase may be facilitated by gently massaging the abdomen or changing position

-dextrose is most often used osmotic agent in PD solutions

• can lead to problems w/ hypertriglyceridemia, hyperglycemia, and long-term peritoneal membrane dysfunction

Systems:

-Automated peritoneal dialysis (APD) = allows pt to do dialysis while they sleep

• cycler delivers dialysate during sleep and controls fill, dwell, and drain phases; alarms and monitors for safety

-Continuous Ambulatory Peritoneal dialysis (CAPD) = done every few hrs during the day

• usually 4 times daily

PD complications

Exit site infection:

-manifestations include redness at the site, tenderness, and drainage

-if not treated quickly, sub-q tunnel infections may progress and cause peritonitis

Peritonitis:

-results from contact contamination or an exit site or tunnel infection

• most often occurs bc of improper technique when connections for exchanges are contaminated

-main manifestations are abdominal pain, rebound tenderness, cloudy peritoneal effluent w/ ↑WBC count

-GI manifestations may include diarrhea, vomiting, abdominal distention, and hyperactive bowel sounds

-antibiotics can be given orally, IV, or peritoneally

-repeated infections may require removal of PD catheter and change to HD

Hernias:

-occurs in predisposed persons (multiparous women and older men) due to increased intraabdominal pressure from the dialysate volume

Lower Back problems:

-increased intraabdominal pressure causes or worsens lower back pain

• orthopedic binders and a regular exercise program for strengthening the back muscles are helpful for some pts

Bleeding:

-after placement normal for effluent to be pink or slightly bloody

-bloody effluent over several days or new appearance can be indicative of active peritoneal bleeding

• check BP and Hct

Pulmonary Complications:

-atelectasis, pneumonia, and bronchitis may occur due to repeated upward displacement of diaphragm

• frequent repositioning and deep-breathing exercises can help

• elevate HOB

Protein Loss:

-unresolved peritonitis can cause excessive protein loss that can result in malnutrition

Effectiveness of PD

main advantage of PD is its simplicity

-home-based program = increases pt participation in care

-learning and skills needed takes 3-7 day training

-no need for special water systems

-equipment setup is fairly simple

Hemodialysis (HD)

requires a very rapid blood flow and access to a large blood vessel

• obtaining vascular access often one of the biggest problems

Arteriovenous fistulas (AVF):

-usually created in the forearm or upper arm w/ an anastomosis btwn an artery and a vein

-allows arterial blood to flow through the vein = vein becomes “arterialized” = increases in size and develops thicker walls

-should be placed 3 months before HD to begin

-preferred access for HD

-thrill can be felt on palpation and bruit can be heard on auscultation of the fistula

Arteriovenous grafts (AVGs):

-made of synthetic materials to form a “bridge” btwn the arterial and venous blood supplies

-2-4 weeks typically needed to allow graft to heal

-more likely to become infected and tend to form clots

-Hemodialysis Reliable Outflow (HeRO) graft = special bridge access used when other access options are exhausted

• 2 pieces = 1 is reinforced tube to bypass blockages, the other is a dialysis graft anastomosed to an artery; placed under skin

Temporary Vascular Access:

-when immediate vascular access is needed catheterization of internal jugular or femoral vein is done

-usually have a double external lumen 

• one lumen used for blood removal and the other for blood return

-have high rates of infection, dislodgement, and malfunction

• pt should not be discharged home w/ temporary catheter in place

-long-term cuffed catheters are used when waiting for AVF or other forms failed

• exit on upper chest and tunneled to internal or external jugular vein

• tip is in right atrium

• 1 or 2 cuffs that prevent infection and anchor catheter

Hemodialysis procedure

-HD dialyzer is a plastic cartridge that contains thousands of parallel hollow tubes or fibers; semipermeable membranes

• ultrafiltration, diffusion, and osmosis occur

Before HD treatment:

-assess fluid status

• weight, BP, peripheral edema, heart and lung sounds

• weight from last post-dialysis and current weight pre-dialysis determines how much fluid will be removed

-assess vascular access, temp.,

-monitor vital signs every 30-60 minutes

During procedure:

-2 large bore needles placed in fistula or graft

• 1 needle is placed to pull blood from circulation to HD machine

• other needle is used to return dialyzed blood to the pt

-Heparin is added to prevent clotting

-dialysate delivery and monitoring system is used

HD complications

Vascular access:

-steal syndrome = pain distal to access site, numbness or tingling of fingers that may worsen during HD, nd poor capillary refill caused by too much blood be “stolen” from the distal extremity

Hypotension:

-often results from rapid removal of vascular volume, decreased cardiac output, and decreased systemic vascular resistance

-may cause lightheadedness, vomiting, seizures, vision changes, and chest pain from cardiac ischemia

Muscle cramps:

-risk factors for development include = hypotension, hypovolemia, high ultrafiltration rate (UFR), and low-sodium dialysis solution

-treatment includes reducing UFR and giving fluids (hypertonic glucose is preferred)

Loss of blood:

-may result from blood not being completely rinsed from dialyzer, accidental separartion of blood tubing, dialysis membrane rupture, or bleeding after removing the needles at the end of HD

-received too much heparin or has clotting problems, postdyialysis bleeding can occur

Hepatitis:

-less common now due to vaccination of Hep B

-infection control precautions are mandated in caring for pts w/ Hep C 

HD effectiveness

-cannot fully replace normal functions of kidneys

-can ease many symptoms of CKD, and if started early can prevent certain complications

-CVD (stroke, MI) causes most deaths. Infectious complications are second leading cause of death

Continuous renal replacement therapy (CRRT)

method for treating AKI

-uremic toxins and fluids removed while acid-base status and electrolytes are adjusted slowly and continuously in a hemodynamically unstable pt

• over 24 hrs

• can be used w/ HD

-contraindicated if pt has life-threatening manifestations of uremia = hyperkalemia, pericarditis

-vascular access is achieved w/ a double lumen catheter as used in HD; placed in jugular or femoral vein

-infusion of replacement fluid determined by degree of fluid and electrolyte imbalance

-anticoagulants needed to prevent blood clotting

-can be continued as long as 30-40 days

• hemofilter should be changed every 24-48hrs

-able to obtain specimens

-ultrafiltrate should be clear yellow

• if bloody, need to terminate

Specific nursing interventions:

-obtain daily weights

-monitor and document lab values daily for fluid and electrolyte balance

-assess hourly intake and output, vital signs, and hemodynamic status

-care for site to prevent infection

CRRT vs HD

-blood pump is slower than HD

-contiunous rather than intermittent

-solute removal by convection (no dialysate required) in addition to osmosis and diffusion

-causes less hemodynamic instability

-does not need constant monitroing by specialized HD nurse but DOES required trained ICU nurse

-does not require complicated HD equipment

-fluid volume can be removed over days vs hrs

Wearable artificial kidney (WAK)

-recently developed and approved for use

-miniaturized dialysis machine that weighs approx. 10lbs

• carrier resembles a tool belt

-connects to pt via catheter

-designed to filter blood in ESRD

-can run continuously on batteries

Kidney transplant 

best treatment for ESRD

-very successful; 1-year graft survival rate

• deceased donor transplants = 90%

• live donor transplants = 95%

-reverses pathophysiologic changes associated w/ renal disease

-eliminated dialysis and dietary and lifestyle restrictions (should still encourage lifestyle chnages)

-less expensive than dialysis after 1 year

Recipient selection:

-candidacy is determined by a variety of medical and psychosocial factors. Careful evaluation is done to identify and minimize potential complications after transplant

• possible exclusions = obesity, smoker

-preemptive transplant (before dialysis is required) is possible if recipient has a living donor

-Contraindications to transplant:

• advanced cancer

• refractory/untreated heart disease

• chronic respiratory failure

• extensive vascular disease

• chronic infection

• unresolved psychosocial disorders

*HIV+ or Hep B or C are NOT contraindications

-surgical procedures may be required before transplant = coronary artery bypass or coronary angioplasty; cholecystectomy; bilateral nephrectomy

Donor sources (kidney transplant)

donors can include deceased donors w/ compatible blood type, blood relatives, emotionally related living donors, altruistic living donors, paired organ donation

Live donors:

-undergo an extensive evaluation to ensure that they are in good health and have no hx of disease that would place them at risk for developing disease or operative complications

-crossmatches done to ensure no antibodies to the donor are present

-advantages of live donors include: better pt and graft survival rates; immediate organ availability; immediate function/minimal cold time; opportunity to have recipient in best possible medical condition since elective surgery

-see nephrologist for H&P

• 24 hr urine = creatinine clearance and total protein

• CBC, chemistry and electrolyte profiles

• Hep B and C, HIV, CMV testing

-diagnostic studies include = ECG, CXR, renal US, arteriogram, 3D CT scan

-Psychologist or social work evaluation for = emotional stability, risks and benefits, cost covered by recipient’s insurance, no compensation for lost wages

Paired Organ donation:

-if ABO incompatibility btwn donor and recipient the find another donor/recipient pair with whom they can excahnge kidneys

• if pair A/B are ABO incompatible find another pair (C/D) and swap kidney donors = A now donates to D and C now donates to B

-plasmapheresis is also an option = removes antibodies from the recipient. After transplant has more treatment

Deceased donors:

-fairly healthy persons who have irreversible brain injury and are declared brain dead

• must have effective CV functions and on ventilator to preserve organs

-permission of next of kin requested even w/ signed donor card

-kidney removed a preserved up to 72 hrs

• preferred cold time less than 24hrs

Kidney transplant procedure

Live donor procedure:

-donor nephrectomy performed by transplant surgeon

-begins 1 or 2 hrs before the recipient’s surgery is started

-recipient is surgically prepared in a nearby operating room

-laparoscopic donor nephrectomy

• most common approach for removing kidney in living donor

• minimally invasive = fewer risks, shorter recovery time

-open (conventional) nephrectomy

• lateral incision

• rib may be removed

Recipient:

-transplanted kidney usually placed extroperitoneal in the iliac fossa

-right iliac fossa preferred for anastomosis of blood vessles and ureter

-before incisions:

• urinary catheter placed into bladder, antibiotic instilled → distends bladder and decreases risk of infection

-rapid revasularization is critical to prevent ischemic injury to kidney

• donor artery anastomosed to recipient internal or external iliac artert

• donor vein anastomosed to recipient external iliac vein

-when anastomoses are completed, clamps are released and blood flow is reestablished → kidney should become firm and pink and urine may begin to flow from ureter immediately

• donor ureter tunneled through bladder submucosa (ureteroneocystostomy)

Nursing management of kidney transplant

Pre-op:

-emotional and physical preparation

• stress that dialysis may be required

• review need for immunosuppressive drugs and prevention of infection

-ECG

-CXR

-lab studies

-dialysis, if needed

Post-op:

Live donor:

-care is similar for laproscopic and open procedure

-monitor renal function to assess for impairment and the Hct to assess for bleeding

-donors usually have more pain than recipient

-acknowledge their gift

Recipient:

-priority is maintaining fluid and electrolyte imbalance

-large volumes of urine may be produced soon after transplanted kidney placed due to 

• new kidney’s ability to filter BUN

• abundance of fluids during operation

• initial renal tubular dysfunction

-first 24hrs in ICU

-dehydration must be avoided

-assess for hyponatremia/hypokalemia due to rapid diuresis

-acute tubular necrosis (ATN) can occur

-monitor urine output; maintain catheter patency

-Pt education: s/sx of rejection, infection and surgical complications; follow-up care

Immunosuppressive therapy:

-adequately suppress immune response to prevent rejection

-maintain sufficient immunity to prevent overwhelming infection

Kidney transplant complications

Rejection:

-hyperacute: antibody-mediated, humoral. Occurs minutes to hrs after transplant

-acute: occurs days to months after transplant

-chronic: process occurs over months or years and is irreversible. May go back on transplant list

Infection:

-significant cause of mortality after transplant

-common infections seen in first month = pneumonia, wound infections, UTIs, IV line and drain infections

-fungal and viral infections are common

• fungal = hard to treat, require prolonged treatment periods, and often involve admin of nephrotoxic drugs. Usually receive prophylactic antifungals

• CMV is one of most common viral infections

• viral infections can be primary or reactivations of existing disease

Cardiovascular disease:

-CVD is leading cause of death after a kidney transplant

-recipients have increases incidence of atherosclerotic vascular disease

-immunosuppressants can worsen HTN and dyslipidemia

-control risk factors = adherence to prescribed antihypertensives

Cancer:

-primary cause is immunosuppressive therapy

-most common types of cancer after transplant

• skin cancers

• posttransplant lymphoproliferative disorder

-regular screening is important

-preventative care include protecting clothing and sunscreen

Recurrence of Original Disease:

-glomerulonephritis

-IgA nephropathy

-diabetic nephropathy

-focal segmental sclerosis

Corticosteroid-related complications:

-aseptic necrosis of hips, knees, and other joints

-peptic ulcer disease

-diabetes and glucose intolerance

-cataracts, dyslipidemia, infections, cancers