kidney med surg

Nephron

Functional unit of the kidney that filters blood and makes urine

Glomerulus

Small network of capillaries encased in the head of the nephron; Filters wastes.

UTI can be in the

bladder, kidneys, ureters, or urethra

Uncomplicated UTI

No anatomical abnormalities in the renal system and kidney function is not impaired; No associated diseases and the risk of serious complication development is low.

Complicated UTI

Occurs in clients who have comorbidities such as diabetes, who are pregnant, or immunocompromised

Acute uncomplicated cystitis

UTI that only affects the lower urinary tract structures

Acute uncomplicated cystitis manifestations

Urgency, dysuria, and suprapubic pain.

Acute uncomplicated pyelonephritis

Affects only the upper urinary tract structures

Acute uncomplicated pyelonephritis manifestations

Flank pain and a fever greater than 38C

Asymptomatic bacteriuria

Positive urine culture without clinical manifestations.

Urethritis

UTI involving the urethra; Presents with discharge from the urethra and burning with urination.

Cystitis

UTI involving the bladder; Presents with hematuria, lower abdominal pain, pelvic pressure, and frequency and dysuria.

Pyelonephritis

UTI involving the kidneys; Presents with flank or back pain, nausea and vomiting, chills, and a high fever.

UTI is described as recurrent if

Client has two or more within six months or three within 12 months

Catheter-associated urinary tract infection (CAUTI)

A UTI caused by an indwelling catheter being present for greater than two days

CAUTI cause

Biofilms form on the catheter surface and bacteria enter the urinary system during catheter insertion or migrate up the catheter to the urethra

When does urine become unfavorable for bacteria

If the urine pH is less than 5, there are high urea levels, or there are organic acids in the urine

How does e. coli attach

The bacteria have surface adhesions that attach to urothelial surfaces

UTI risk factors

Female, catheter, sexual intercourse, poor hygiene, frequent pelvic examinations, bubble baths, and usage of diaphragms and condoms with spermicidal foam

Urosepsis

Systemic infection that starts in the urogenital tract and can occur if UTI if left untreated.

Why does Diabetes increase chances of UTI

They have decreased levels of a peptide with antimicrobial properties called Psoriasin which compromises the integrity of the bladder's cell barrier; Sugar also is a great breeding ground for bacteria; Decreased sensation may make them unaware of needing to use the bathroom.

Males chances of developing UTI increase with

Enlargement of the prostate

Limits UTI in post-menopausal women

They may have atrophic vaginitis (dry and thin vagina walls) so estrogen vaginal cream can be used to limit risk

Clean catch instructions

Spread labia apart; Clean urethra with three sterile wipes by first wiping the inner fold on one side, then the second inner fold, and then directly over the urethra; Urine is collected midstream without the cup touching.

Dipstick testing

Tests urine pH, hematuria, leukocyte esterase, and nitrites; Most accurately detects UTI through nitrites since urine must contain bacteria for the conversion of nitrates to nitrites

Normal urine pH

4.5 and 8.0, usually between 5.5 and 7.5

Leukocyte esterase testing in dipstick

Detects WBCs in the urine, but they may also be present in inflammatory disorders and other conditions.

Hematuria may be present in

Vaginitis or urethritis, not usually present for an uncomplicated UTI.

Urine culture

Collected midstream; Determines the specific cause of the infection; Blood usually also taken for CBC to determine if there are elevated WBC which would show a systemic infection.

Cranberry can prevent UTI because

It effects the ability of bacteria to adhere to the uroepithelium.

Duration of UTI manifestations after starting treatment

2 to 4 days

Trimethoprim/Sulfamethoxazole (Bactrim)

First line antibiotic, usually for 3 days but it has high resistance rates; Sulfonamide/anti-infective.

Bactrim action

Stops two steps necessary in the bacteria replication process; Metabolized in the liver and excreted through the kidney.

Bactrim contraindications

Sulfa drug allergy, pregnant; Used cautiously in clients with hepatic or renal impairments

Bactrim Adverse reactions/side effects

Stevens-Johnson syndrome, hypoglycemia, diarrhea caused by Clostridium difficile, and aplastic anemia.

Bactrim administration

IV or orally; Taken with a full glass of water

Nitrofurantoin Action/ Administration

Anti-infective that interferes with bacteria enzymes; Metabolized in the liver and excreted through the kidneys; Used for 5 to 7 days orally 4x a day with food or drink

Nitrofurantoin Contraindications/ Adverse Reactions

Contraindicated with Parabens sensitivity; Used with caution in older clients, decreased renal or hepatic function, or breastfeeding; Adverse reactions include pulmonary fibrosis, hepatotoxicity, and diarrhea associated with Clostridium difficile

Nitrofurantoin Monitoring

Creatinine clearance and liver function tests to monitor for potential issues; Urine may become rust-yellow or brown in color and that is a normal finding

Ciprofloxacin (Cipro)

Fluoroquinolone; Has high rates of resistance but are widely prescribed for UTI; Anti-infective that prevents the fusion of bacterial DNA; Effective for gram-positive pathogens.

Ciprofloxacin Contraindications/ Adverse Reactions

History of myasthenia gravis or pregnant; Usage of tizanidine and theophylline (increases levels), phenytoin, or NSAIDs; Used cautiously with seizure and depression history; Adverse reactions are intracranial pressure, seizures, suicidal thoughts, Stevens-Johnson syndrome, hepatotoxicity, and diarrhea caused by Clostridium difficile.

Ciprofloxacin (Cipro) administration

Orally or IV for 7 to 14 days; With or without food, but cannot take with an antacid or medications that contain zinc or iron because they alter the absorption.

Phenazopyridine (Pyridium)

Given for UTI pain; Contraindicated with renal or hepatic impairment. Adverse reactions include hepatotoxicity, rash, renal failure, and bright orange urine; Taken orally with a full glass of water; Stains contacts and clothes.

Stress incontinence

Caused by weakness of the urethral sphincter or pelvic floor muscles; leakage with sneezing, coughing, or physical exertion

Urge incontinence

Caused by detrusor muscle overactivity that causes bladder contraction, loss of neurologic control, or bladder irritation; Sense of urgency that precedes or accompanies leakage of urine.

Overflow incontinence

Caused by overdistended bladder from a bladder obstruction or impaired contractility of the detrusor muscle;

Pelvic organ prolapse cause

Occurs in females when pelvic muscles can't hold the internal structures (uterus and cervix) in place, making them protrude into the vagina; Associated with vaginal childbirth deliveries, or intra-abdominal pressure from chronic cough, continuous heavy lifting, or obesity.

Hysterectomy may result in

Decreased bladder capacity and damage to the pelvic nerves

Pelvic organ prolapse manifestations

Risk for overflow incontinence because the bladder may be unable to fully empty, and with the fall of the bladder and internal organs, the ureters may become twisted or kinked.

BPH manifestations

Difficulty starting stream, dysuria, nocturia, urgency, urine retention, weak urine stream, and dribbling after toileting; Overflow incontinence.

Temporary Urinary Incontinence causes

Alcohol, chili peppers, very spicy or sugary foods, chocolate, carbonated drinks, and caffeine

HTN medications cause

Urinary incontinence exacerbation

Diuretics, such as Lasix (furosemide) cause

Increased urge and frequency of urination

Alpha blockers, such as Doxazosin (Cardura) cause

Bladder and neck muscle relaxation causing stress incontinence or leakage.

Antidepressants cause

Altered bladder contractility, which worsens overflow incontinence.

Under-active bladder conditions

Neurological conditions such as Parkinson's disease, multiple sclerosis, or spinal cord injury

Most common type of urinary incontinence in females

Stress incontinence

Overflow incontinence diagnostic criteria

If bladder scan finds over 200ml post-void residue

Urinary retention diagnostic criteria

Over 400 mL in the bladder after trying to urinate

Chronic urinary retention diagnostic criteria

Post-void volume over 300 mL that for at least six months documented on two or more separate occasions

Post-obstructive diuresis

An immediate return of over 1,500 mL of urine after catheterization

BPH treatments

Prostatectomy to remove the entire prostate gland (usually for super large prostates over 100 g); Transurethral incision on the prostate (TUIP) in the bladder neck to widen the channel; Transurethral needle ablation (TUNA) uses a cystoscope with curved needles that deliver radiofrequencies to cause thermal necrosis in the prostate; Photoselective vaporization of the prostate (PVP) uses a tissue-specific laser to destroy prostate tissue (used for clients on anticoagulant therapy)

Acute pyelonephritis

severe kidney infection that occurs suddenly and causes the kidneys to swell

Chronic pyelonephritis (reflux nephropathy)

Rarer than the acute; Diagnosed with repeated instances of acute pyelonephritis, usually in clients with obstructions.

Pyelonephritis usually develops from

A lower UTI that spreads to the kidneys through the ureters

Bacteria that cause pyelonephritis

Gram-negative bacteria such as E. Coli, Klebsiella, Enterobacter, and Proteus, which are present in feces.

Complications from Acute Pyelonephritis

Formation of renal abscesses, thrombosis in the renal vein, emphysematous pyelonephritis, and acute renal failure

Emphysematous Pyelonephritis (EPN)

Necrotizing infection that destroys the kidney tissues; Severe complication of Pyelonephritis linked to Diabetes; Caused by e. Coli or Klebsiella pneumoniae

Pyelonephritis Epidemiology

Young and sexually active females are the most affected; 1/3 of pregnant women develop acute pyelonephritis in the 2nd to the beginning of the 3rd trimester due to increased progesterone and pressure on the ureters.

Pyelonephritis in pregnant client treatment/ risks

Beta-lactam antibiotics for 24 hr; Can cause premature delivery and death.

Pyelonephritis manifestations in children

Failure to thrive, fever, and difficulty with feeding.

Acute Pyelonephritis can lead to

Scarring of the parenchyma of the kidneys, sepsis, shock, or acute renal failure.

Manifestations associated with kidney disease

Fatigue, swelling in the ankles, or pruritus; May also occur in asymptomatic chronic pyelonephritis clients when an acute infection occurs

Dimercaptosuccinic acid (DMSA) test

Shows scarring in the urinary tract from pyelonephritis; A radioactive material is injected into the arm, and images are taken of the material's passage through the kidneys

Polycystic Kidney Disease

Inherited disorder that causes fluid-filled cysts to develop in the kidneys, impairing their function, and potentially leading to renal failure.

ADPKD (Autosomal Dominant polycystic kidney disease)

Normally diagnosed in adulthood (30 to 50 years old); ADPKD1 gene accounts for 85% of cases (manifestations appear sooner), ADPKD2 gene accounts for 15% (progress quicker to end-stage renal disease)

ARPKD (Autosomal Recessive Polycystic Kidney Disease)

Diagnosed pre- or post-birth when found with kidney cysts that enlarge and decrease kidney function, creating breathing difficulties that claim the lives of 30% of newborns within 1 week of birth

ADPKD manifestations

Flank pain, polyuria, nocturia, palpable kidney masses, hematuria, hypertension, and proteinuria.

PKD increases chances of developing

Cysts in the liver and pancreas, renal calculi, cardiac disease, cerebral aneurysms, and colonic diverticula.

ADPKD cardiovascular defects

May develop mitral valve prolapse, ventricular hypertrophy, or aneurysms (can be lethal if pops).

PKD with severe headache indicates

Cerebral aneurysm

Renal mass can be due to

PKD, cancer

End stage kidney failure in ADPKD

Develops usually between 50-60 yo in half of patients

PKD testing

Renal ultrasound or a CT scan to evaluate the size and number of cysts present, or the number of healthy kidneys

PKD maintenance

Low-protein diet depending on test results; Low-sodium diet for blood pressure; Refrain from smoking because it damages kidneys; No NSAID's unless cleared by provider.

PDK pathological process

Fluid-filled cysts that damage the nephrons in the kidney as they grow, which impairs renal function causing renal failure; Polyuria and nocturia in early stages, and oliguria as the kidneys continue to fail; May cause UTIs and pyelonephritis from urine obstruction

Tolvaptan

Slows cyst growth by inhibiting vasopressin (causes cysts to grow), decreases water retention while preserving sodium, and decreases pain.

Glomerulonephritis

A group of renal diseases where glomerulus is damaged due to immune reactions, which and results in proteinuria, azotemia, and hematuria

What causes decreased GFR in Glomerulonephritis

Inflammation

Clinical manifestations of glomerulonephritis

Periorbital edema, dark and frothy urine, elevated blood pressure, weakness, fever, malaise, and abdominal pain.

Acute glomerulonephritis

Caused by a primary renal cause or by an illness that impairs renal function; Abrupt onset cases usually caused by streptococcus

Chronic glomerulonephritis

Slow progressive process that will lead to renal failure after years of proteinuria and hematuria

Rapidly progressive (Acute) glomerulonephritis complications

Antibodies cause a sharp decline in glomerular function, and cell hyperplasia in the Bowman's capsule

Post-streptococcal glomerulonephritis

Diagnosed if glomerulonephritis presents 1 or 2 weeks after the client recovers from a strep throat infection or impetigo

Bacterial endocarditis

An infection of the endocardial lining of the heart that is linked to causing glomerulonephritis

Hepatitis B and C and HIV

Create inflammation of kidney tissues, including the glomeruli

Goodpasture's syndrome

Autoimmune disorder where antibodies attack the kidneys and lungs

IgA nephropathy (Berger's disease)

Caused by antibody accumulation in the glomeruli; Common manifestation is hematuria

Polyarteritis

Affects small and medium blood vessels in the kidney and other parts of the body and can cause glomerulonephritis

Granulomatosis with polyangiitis (Wegener's granulomatosis)

Also affects the small and medium blood vessels, but the blood vessels in the lungs and upper respiratory tract are also affected