Complex-Renal part 1

What is the primary purpose of the urinary system and kidneys?

Remove waste products/drugs from the body​
Balance the body's fluids​
Release hormones to regulate blood pressure​
Control production of red blood cells

What do the kidneys regulate?

• Body osmolarity & volume

• Electrolytes

• Acid-base balance

• Blood Pressure (BP)

What do the kidneys secrete? (hormones)

• Erythropoietin for RBC production

• 1,25-dihydroxycholecalciferol for vitamin D metabolism

• Renin

• Prostaglandin

What do the kidneys Excrete?

• Metabolic waste products

• Foreign substances (drug metabolites)

• Excess fluid

• Excess electrolytes

How do the kidneys regulate Osmolarity and volume?

Na+ & H2O balance​

Thus, maintaining extracellular fluid volume (ECFV) homeostasis

What is the normal pH range?

7.35-7.45

What is the normal CO2 range?

35-45 mmHg

What is the normal HCO3 range?

18-24 mEq/L

What is the PaO2 normal range?

>90 mmHg

What is the normal SaO2 range?

94-100%

What Acid-Base imbalance is indicated if there is elevated CO2?

Acidosis (respiratory)

What Acid-Base imbalance is indicated if there is decreased CO2?

Alkalosis (respiratory)

What Acid-Base imbalance is indicated if there is an increased HCO3?

Alkalosis (metabolic)

What Acid-Base imbalance is indicated if there is a decreased HCO3?

Acidosis (metabolic)

How does the Cardiovascular center regulate BP?

within the brain, impacts BP (↑ or ↓) rapidly by adjusting CO or blood vessel dilation by way of:​

• The Sympathetic nervous system ↑ HR & vasoconstricts​

• The Parasympathetic nervous system ↓ HR (vagus nerve) and vasodilates ​

• Baroreceptors- mechanosensitive nerve endings in carotid sinuses and aortic arch- function as arterial BP sensors; very sensitive & CX a reaction within milliseconds​

How do the kidneys regulate BP?

by releasing hormones:​

• The Renin-Angiotensin-Aldosterone System (RAAS) controls blood volume (BP) and construction of blood vessels (also BP) by releasing hormones​

Why would the kidneys secrete EPO?

Produces RBCs and thus increases volume

Why do the kidneys secrete enzymes? (specifically 25-dihydroxyvitamin D3)

Converts inactive Vitamin D to active Vitamin D for Ca++ metabolism and maintains C++ balance in the body-bones! ​

Why do the kidneys secrete Renin?

Converts angiotensinogen into angiotensin I

Why do the kidneys secrete Prostaglandins?

These are lipids that help regulate renal hemodynamics by controlling Na+ & H2O and helps in regulating the renin-angiotensin system​

What Renal Specific Health History is needed?

• Chief complaint ​

• Changes in voiding (hesitancy/frequency?)​

• Any DX procedures/surgeries or catheters? ​

• OB/GYN history (female pts)​

• Kidney stones (current or PMH of)​

• S/S of anemia ​

• Gastrointestinal s/s​

• Medications (including OTCs) ​

• Tobacco (↑ risk for certain kinds of CA)​

• Illicit drugs or alcohol abuse ​

• Advanced age?​

• Any other risk factors?​

In a Genitourinary Focused Assessment, what cardiac measures would the nurse check?

• Heart sounds (added heart sounds could mean fluid volume overload)​

• Vitals (ECG for dysthymias)​

• Central Venous Pressures (if possible) tells systemic volume status

In a Genitourinary Focused Assessment, what Pulmonary measures would the nurse check?

• Breath sounds (fluid volume overload?)​

• Chest X-ray (fluid?)​

• O2 Sats (can indicated fluid issues if low)

In a Genitourinary Focused Assessment, what Neurological measures would the nurse check?

• Confusion? ​

• Could be a sign of toxicity if they have renal function issues.

In a Genitourinary Focused Assessment, what Integumentary measures would the nurse check?

• Dry skin/lips/mouth-hydration status?​

• Color-Pallor? Patchy, itchy?

In a Genitourinary Focused Assessment, what Bladder measures would the nurse check?

• Palpate and ask about sensation, voiding issues, how much​

• UOP (observed and a discussion with the patient)

In a Genitourinary Focused Assessment, what Circulatory system (vitals) would the nurse check?

• ↑BP could mean too much systemic volume (poor kidney function?)​

• ↓ BP and ↓HR-dehydration/fluid volume depletion?​

• CVP if available

What is considered a Normal Urine Output (UOP)?

0.5 to 1.5 cc/kg/hour at least every 6 hours (at least 30cc/hour or 800-2L per day)

What is considered Excessive Urine Output?

• Frequency - frequent voiding more than every 3 hours​

• Polyuria - ↑ volume of urine voided

What is considered Poor Urine Output?

• Oliguria – decreased UOP < 0.5 mL/kg/hour (less than 400 in a day)​

• Anuria – means “without” urine

What things are found in our urine?

• Bacteria ​

• Protein ​

• Blood ​

• Sugar (glycosuria)

What can cause Oliguria? (UOP< 400mL/24 hr or <0.5mL/kg/h for 6hrs) (when it comes to the renal system)

AKI, CKD, dehydration

What can cause Anuria? (UOP<50mL/day)

AKI/CKD

What is a possible cause of Dysuria? (Difficulty voiding or Pain with urination)

• Lower UTI, inflammations of the blader/ureter/ prostatitis

• kidney stones, foreign bodies, bladder tumors

What is a possible cause of Urinary Frequency? (more than every 3 hours)

• UTIs, obstruction of the ureters, anxiety, diuretics

• benign prostatic hyperplasia (BPH), diabetic neuropathy

What is the possible cause of Urinary Hesitancy? (Delay or difficulty initiating voiding)

BPH, neurogenic bladder, obstruction, stones

What is the possible cause of Nocturia? (Awake at night to urinate)

Diabetes, heart failure, nephrotic syndrome, excessive water intake, cirrhosis

What is the possible cause of Polyuria? (Increased volume of urine voided)

Diabetes, DI, diuretics, excessive fluid intake, lithium toxicity, KDs​

What is the possible cause of Bacteriuria? (Bacterial count >100,000 colonies/mL in urine)

Infection

What is the possible cause of Hematuria? (RBCs in the urine)

CAs, Acute glomerulonephritis, kidney stones, blood dyscrasias, sickle cell, rheumatic fever, extreme exercise, trauma

What is the possible cause of 3+ RBC (hematuria) in a urine analysis?

Infection, stones, neoplasm, trauma

What is the possible cause of Proteinuria in a urine analysis?

Benign finding (fever, exercise), DMII, HF, medications

What is the possible cause of altered specific gravity in urine analysis?

hydration status

What is the possible cause of Glucose in Urine Analysis?

Diabetes, pregnancy, kidney pathology

What is the possible cause of Casts in a urine analysis?

Dehydration, fever, HF, many kidney diseases

What is the possible cause of Leukocyte esterase and nitrate in a urine analysis?

Assoc. w/ increase WBC and infection

What are older adults at risk for with their kidneys?

• Acute and chronic renal injury ​

• Incomplete bladder emptying (structural changes)​

• Adverse drug effects and drug-drug interactions​

• Hypernatremia and fluid volume d/t ↓ thirst​

• Urinary incontinence much more common​

• UTI especially in older women​

• Polypharmacy is an issue​

• Often there is a loss of body mass (might need different RX dosage)​

What diagnostics is used to evaluate kidney function?

Renal function tests (Serum)

What do common serum lab tests check for?

• Na+ (135-147 meq/L)

• Cl (95-106 meg/L)

• BUN (6-20 mg/dL)

• K+ (3.5-5.2 meq/L)

• CO2 (22-30 meq/L)

• SCr (0.6-1.3 mg/dL)

• Glucose (70-110 mg/dL)

What is Blood Urea Nitrate (BUN) and what does it tell us?

Serum BUN is one expression of renal function and fluid volume

• The urea travels from your liver to your kidneys through your bloodstream​

• Healthy kidneys filter urea and remove other waste products from your blood​

• The filtered waste products leave your body through urine

What are some causes of Elevated Serum BUN levels? (Source-Blood)

• Dehydration ​

• Urinary tract obstruction​

• Congestive heart failure ​

• Recent heart attack​

• Certain medications​

• Shock ​

• High protein diet

What is Serum Creatinine (SCr) and what does it tell us?

​A chemical compound left over from energy-producing ​processes in your muscles (creatinine)​

• Healthy kidneys filter creatinine out of the blood​

• Creatinine exits your body as a waste product in urine​

• Tells us about the function of the kidneys

What are some of the causes of Elevated Serum Creatinine Levels?

• Kidney infection​

• Glomerulonephritis (inflammation of kidney structures that filter blood)​

• Kidney stones (can block the urinary tract)​

• Kidney failure ​

• Temporary elevations (causes can be multiple)

What does Glomerular Filtration Rate (GFR) do?

Tells how well the kidneys are working: Estimates how much blood passes through the glomeruli each minute

What is a Kidney, Ureter, and Bladder (KUB) study?

• Delineates size/shape/position of kidneys

• Reveals urinary system abnormalities

• Can be done at bedside: often 1st diagnostic performed

• Less costly than other diagnostics

What is a Renal Ultrasound?

• Noninvasive view of GU system

• Identifies:

  • Fluid accumulations

  • Masses

  • Congenital abnormalities

  • Obstructions

What does a CT scan identify in relation to renal issues?

• masses, stones, infection, trauma

• metastasis, soft tissue abnormalities

• Can be used w/ contrast to enhance visualization

What needs to be done Pre-procedure prior to IVP dye (contrast dye)?

• Allergy history (shellfish/contrast dye?)​

• DC nephrotoxic meds (NSAIDS, metformin, vancomycin, etc.) ​

• IV access​

• Assess & Monitor kidney function

What Pre-procedure labs need to be drawn prior to IVP (contrast) dye injection?

• (CMP-Creatinine, BUN, GFR)​

• Alert healthcare team of any abnormal renal labs​

• Administer an antihistamine (if patient allergic)

What pre-procedure medications are needed prior to IVP (contrast) dye injection?

• Patients with AKI/CKI: IV Mucomyst (N-acetylcysteine) ​

• Mucomyst-Contraindicated with sulfur allergies​

• NS IVF before, during, after the procedure (for non EKD pts) ​

What is needed post-procedure in relation to IVP (contrast) dye?

• Complete Metabolic Panel

  • Alert medical team of abnormal renal labs

• IVF (NS-preferred)

  • After contrast dye, flush the kidneys

• Strict observation of UOP

  • one of the most valuable assessments for AKI

What is Cytoscopy?

Uses a scope to view the inside of the bladder and urethra

What does a Cytoscopy check for?

• bladder cancer

• bladder control issues

• enlarged prostate

• urinary tract infections

What does a Kidney biopsy help to diagnose/evaluate?

• kidney disease (and severity)

• Unexplained AKI

• Persistent Proteinuria/hematuria

• Transplant rejection

• Glomerulopathies

What is needed pre-op before a Cystoscopy and Renal Biopsy?

• Describe the procedure​

• NPO

What is needed post-op for a Cystoscopy and Renal Biopsy?

• Relieving any discomfort or pain​

• Possible burn when voiding, blood-tinged urine, & urinary frequency ​

• Moist heat to lower abdomen​

• Sitz baths​

What is the formula for the 24-hr creatinine clearance?

Volume of urine (mL/min) x Urine creatinine (mL/dL) / Serum Creatinine (mg/dL)

What are the normal serum BUN levels?

7-20 mg/dL

What are the normal serum creatinine levels?

0.5-1.2 mg/dL

What is the typical GFR for an adult?

90-120 ml/min/1.73 m

What is the typical GFR for an elderly person?

60-89 ml/min/1.73 m

How much urine output is normal per hour?

30 mL (0.5-1.5 cc/kg/hr at least every 6 hrs)

How much urine output is normal per day?

800-2000 mL

What is considered Poor urine output?

< 0.5 mL/kg/hr (less than 400 per day)