renal disorders

kidney function

• filtration of waste and excess substances

• regulation of blood pressure, fluid, and electrolyte balance

• erythropoiesis (red blood cell production)

• metabolism of vitamin D

upper UTI

involving parenchyma, pelvis, or ureters = fever, chills, flank pain (CVA tenderness)

lower UTI

no systemic manifestations

pyelonephritis

inflammation (usually r/t infection) of renal parenchyma and collecting system

cystitis

inflammation of bladder wall

urosepsis

UTI that has spread to systemic circulation (life threatening)

what predisposes someone to UTIs

• neurogenic bladder

  • nerves in bladder don’t signal to brain when to empty

• foreign bodies (kidney stones)

• anatomic factors (females urethra shorter and anatomical position)

• factors compromising immune response

  • aging, DM

• functional disorders (constipation)

• pregnancy, poor hygiene, habitual delay in urination

clinical manifestations of lower UTI

• bladder emptying symptoms

  • hesitancy, intermittency, post-void dribbling, urinary retention/incomplete emptying, dysuria

• bladder storage symptoms

  • urinary frequency, urgency, incontinence, nocturia, nocturnal enuresis

UTIs and women

• most common bacterial infection in women

• typically E coli

• organism originates in ascending route of urethra

UTIs and older adults

• will often not present with classic symptoms

• non-localized discomfort

• cognitive impairment

• generalized clinical deterioration

diagnosis of UTI

• goal - confirm bacteriuria and pyuria

• urinalysis

  • quick dipstick

    • + nitrites

    • increased WBC

    • + leukocyte

  • confirm with microscopic urinalysis

• urine culture may be done if

  • complicated or nosocomial UTI

  • frequent UTI

  • unresponsive to therapy

  • questionable diagnosis

UTI risk factor reduction

• patient teaching - prevention is key

  • empty bladder regularly and completely

  • wipe perineal area front to back

  • drink adequate amounts of fluid daily (2-3 liters)

    • cranberry juice or tablets - no evidence that improves outcomes, worth a try

  • sexually active females - urinate prior to and following sexual intercourse

nosocomial/HAI UTI: risk factor reduction

• urinary catheterization

  • avoid or early removal

• excellent handwashing and glove wearing when giving perineal care

• careful aseptic technique with urinary tract instrumentation

• avoid incontinence episodes

UTI acute interventions

• adequate fluid intake (unless contraindicated)

  • water is best, avoid bladder irritants (caffeine, alcohol, citrus, chocolate, spicy)

• pain relief

  • warm bath or shower

  • local heat to area

• antimicrobial therapy

• patient and family teaching

  • take full course of antibiotics

  • seek follow up care if symptoms do not resolve

    • recurrence within 1-2 weeks following initial infection if inadequate treatment

pyelonephritis clinical presentation

ranges from mild fatigue to sudden onset chills, fever, vomiting, flank pain (CVA tenderness)

pyelonephritis diagnostic tests

• same as UTI diagnostics

• WBC with diff

• imaging tests

• blood culture if suspect bacteremia/urosepsis

collaborative care for mild symptoms of pyelonephritis

• outpatient treatment

• adequate fluid intake

• NSAIDs or antipyretic drugs

• follow-up urine culture and imaging studies

• initially empirically selected broad spectrum antibiotics - switch to sensitivity guided therapy when cultures available

collaborative care for severe symptoms of pyelonephritis

• hospitalization

• adequate fluid intake (parenterally initially; switch to oral when n/v/dehydration subsides)

• NSAIDs or antipyretics

• follow up urine culture and imaging studies

• parenteral antibiotics - switch to oral when tolerates intake

nephrolithiasis

kidney stones

• more men than women

• calculus refers to stone

• lithiasis refers to stone formation

• most patients middle aged

• risk for developing increases with age

diagnostic studies of nephrolithiasis

• careful H&P

• non-contrast spiral CT

• ultrasound

• IVP

• urinalysis (assess hematuria, crystalluria, and pH)

• retrieval/analysis of stones

five major categories of kidney stones

• calcium oxalate (most common)

• calcium phosphate

• uric acid

• cystine

• struvite

management of acute attack of nephrolithiasis

• treat symptoms

  • flank pain - treat with NSAIDs and opioids

  • renal colic - intermittent sharp pain

  • N/V

• infection

  • systemic antibiotics

• obstruction

  • <4mm often passes spontaneously

  • stones >4mm usually do not pass so need stent placement

  • removal of stones

collaborative care of nephrolithiasis

• evaluate cause of stone formation and prevent further development

• teach patient adequate hydration and how to strain urine

• dietary changes, depending on content of stone

  • low oxalate (dark roughage, spinach, cocoa, nuts)

  • low calcium controversial

    • stones may not come from dietary calcium sources

  • low purine (if uric acid)

lithotripsy

• endourologic procedure

• outpatient procedure

• disintegrates stones via shock waves

• approach options

  • internal (direct)

  • cystoscopic approach

  • percutaneous approach

  • laser

  • external (indirect)

    • stones broken down and washed out

    • major advantage - noninvasive

    • possible complications - hemorrhage, infection, retention of stone fragments

lithotripsy: post procedure

• hematuria is common

• stent usually placed to facilitate passage of fragments

  • removed after 1-2 weeks

nephrostomy tube

• used when ureter is totally obstructed for any reason

• surgically inserted into renal pelvis via small flank incision

  • attached to external bag for closed drainage

• considered temporary option

• if excessive pain or drainage around exit site, possible blockage

• if irrigation is ordered

  • strict aseptic technique

  • gently instill no more than 5ml of sterile NS

kidney stones nursing considerations

• goal - patient education, lower risk factors through lifestyle and dietary changes

• fluid intake

  • encourage 3L/day to prevent

  • while managing obstructed stone, FF not advised

  • water preferred

• dietary restrictions

  • determined by type of stone

• reduction of risk factors

  • sedentary/immobilized person

  • adequate fluid intake

  • turn q2 hours

  • stand/sit up to void bladder on regular basis

  • encourage ambulation

• monitoring passing of stones

  • filter all urine through gauze or other filter

• controlling pain

  • difficult to control

  • PCA pump often ordered

  • explore additional non-pharm measures to reduce pain

urinary diversion

• surgical procedure that creates a new way for urine to leave body when bladder is not working properly or has been removed

• incontinent and continent urinary diversions

  • incontinent - require bag to collect urine

  • continent - create pouch within body, allowing internal urine storage and catheterization or natural urination

ileal conduit

• incontinent diversion to skin

• ureter goes through ileal conduit (small intestine) and empties through stoma into collecting bag

continent cutaneous reservoir

• continent diversion to skin

• piece of bowel is taken to make pouch to hold urine, catheter can be inserted into stoma to empty

orthotropic neobladder

• continent diversion to urethra

• pouch made from large intestine and rectum that holds urine, urethra connects to pouch for emptying

incontinent urinary diversion

• ileal conduit

• gold standard for urinary reconstruction before advent of continent diversion

• procedure of choice if significant comorbidities or shorter life expectancy

  • stoma visible

  • permanent external collecting device needed

  • skin integrity and body image concerns

continent urinary diversion: cutaneous diversion

• have been largely replaced by orthotropic neobladder

• no external bags

• intermittent life long clean catheterization required

continent urinary diversion: orthotropic neobladder

• internal reservoirs connected to native urethra

• constructed from segment of intestine (usually ileum) that is separated from bowel and anastomosed to native urethra

• most closely approximates normal voiding, procedure of choice after cystectomy

preop cystectomy management

• address anxiety and fear

• address teaching needs

• include wound, ostomy, and continence nurse (WOCN)

post-op cystectomy management

• NPO and NG to LWS for a few days

• patient teaching

  • ileal conduit

    • ensure properly fitting appliance and provide meticulous skin care

    • expect mucous in urine

    • stomal assessment

  • continent diversion

    • cath every few hours at first, extend to 4-6 over time

  • neobladder

    • void by relaxing sphincter and bearing down (will not feel urge to go) every 2-4 hours

    • practice pelvic floor muscle relaxation to aid voiding