Health Alterations class 11: Elimination, fluids and electrolytes

Anuria

Absence/very small amounts of urine

Dysuria

Painful urination

How many mls are accounted for insensible losses

600 mls (typically, may vary)

Functions of the kidney

1. Urine production (primary function)

2. H2O regulation

3. Excretes waste

4. Electrolyte balance

5. Acid base balance

6. BP regulation (RAA, fluid)

7. Regulates RBC production (erythropoietin)

8. Synthesis of vitamin D

9. Secretes prostaglandins (vasodilator)

Lab tests for renal function that increase with dehydration

1. Specific urine gravity

2. Urine osmolality

3. Serum osmolality

Lab tests for renal function that indicate azotemia and increase with decreased renal function

1. Serum creatinine (decreased creatinine in urine, so increased in blood)

2. Serum BUN (directly related to excretory function of the kidneys)

What does protein in the urine indicate

A problem with the kidneys

Kidney disease

1. Partial or complete impairment of kidney function

2. Inability to excrete metabolic waste products and water

3. Functional disturbances of all body systems

4. Decreased GFR, increased BUN and creatinine

Acute kidney injury (AKI)

1. Sudden/rapid loss of function

2. Reversible if detected and treated early

3. Results in decreased GFR and oliguria

People at an increased risk of developing kidney disease

Patients with cardiovascular issues, severe dehydration, Hypovolemia, DM, contrast dye and IV nephrotic toxic antibiotics (such as vancomycin)

Chronic kidney disease (CKD)

1. Progressive, irreversible deterioration in renal function

2. Want to protect function for as long as possible, once its lost it can’t be restored

How long does AKI last

Hours to days

AKI mortality rate

High mortality if not caught and treated early

Factors contributing to AKI

1. severe prolonged hypotension

2. Hypovolemia

3. Nephrotoxic

4. Improper blood flow

AKI lab values

1. Increased BUN

2. Increased Creatinine

3. Increased potassium

4. May be with or without oliguria

Important consideration for AKI

May have increased potassium, so monitor for cardiac issues (may be fatal)

AKI causes: Prenrenal

Sudden and severe drop in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury or illness

Specific urine gravity

How the kidneys dilute urine (how concentrated urine is)

Urine/serum osmolality

How many dissolved particles are present (In urine or blood)

AKI causes: Intrarenal

Direct damage to the kidneys by inflammation, toxins, drugs, infection or reduced blood supply (pre renal cause that can directly impact kidneys overtime)

AKI causes: Post renal

Sudden instruction of urine flow due to enlarged prostate, kidney stones, bladder tumour or injury. Urine gets backed up into the kidneys

Consideration when administering contrast dye or IV antibiotics that are nephrotoxic (such as vancomycin)

Monitor kidney function

Most common cause of AKI

Acute tubular necrosis

Acute tubular necrosis (ATN) cause

Due to ischemia, nephrotoxins or sepsis

3 phases of AKI

1. Initiation

2. Maintenance

3. Recovery

AKI initiation phase

Increased serum creatinine and BUN and decreased urine output

AKI Maintenance phase

1. Anuric

2. Oliguric or nonoliguric (not getting rid of toxins, still have output)

3. Lasts days to weeks

AKI Recovery phase

1. BUN, creatinine and GFR being to return to normal, takes months to years to stabilize and return to baseline

GFR AKI recovery phase

Want at least 90% but may be 88-89%

Signs and symptoms of ATN

1. Fluid volume excess (decreased urine output can lead to edema, increased BP and crackles)

2. Metabolic acidosis (kidneys produce bicarbonate, acid products of metabolism not excreted, see kussmauls respirations)

3. Sodium/potassium imbalance (hyponatremia-swelling in brain/hyperkalemia-cardiac issues)

4. Hematological disorders (anemia)

5. Calcium/phosphate imbalance

6. Waste product accumulation (organs: brain-confusion, IS space- skin will be tight dry and itchy, increased risk of infection)

7. Neurological disorders (confusion, decreased concentration, seizures, coma, death)

ATN diagnostic testing

1. History and physical (flank/back pain, UTIs, prostate issues, meds, infection, kidney stones, comorbidities, voiding)

2. Urinalysis

3. Renal ultrasound (looking for stones, tumors, structure)

4. CT scan (gets a better look at the inside of the kidney)

5. Blood work (serum creatinine, BUN and electrolytes)

Fluid restriction

600 ml plus previous 24 hour fluid loss

Nutritional therapy

1. Adequate protein, potassium, sodium and phosphate restrict

2. Enteral/parenteral nutrition

Monitor/lower potassium

Prevent life threatening dysthymias (ECG)

What supplements may a person with AKI, CKD or ATN need

Calcium supplements or phosphate binders (may have bone issues, tums are calcium supplement and phosphate binder)

Renal replacement therapy

Dialysis, may be temporary until cause is gone and kidneys have healed

Nephrotoxic IV drugs

Be mindful of bag size as may be on fluid restriction, use smallest and most effective dose

Treatment of hyperkalemia

1. Stabilize myocardium

2. Shift potassium into cells

3. Enhance potassium removal

4. Long term treatment (dietary changes, limit or stop meds that cause hyperkalemia, such as diuretics or ace inhibitors)

Treatment of hyperkalemia that stabilizes the myocardium

Calcium gluconate IV- ECG changes and cardiac monitor

Treatment of hyperkalemia that shifts potassium into cells

1. Regular IV insulin and glucose to prevent hypoglycemia

2. Salbutamol

3. Sodium bicarbonate

Treatment of hyperkalemia that enhances potassium removal

1. Kayexalate (a drink that binds to potassium and excretes it in the stool)

2. Loop diuretics (non potassium sparing)

3. Dialysis (for emergency)

Nursing assessment

1. Vital signs

2. Intake and output

3. Edema assessment (feel, look, ask, sob?, crackles?)

4. Mental status

5. Daily weight (same scale/time, no food and void before)

6. Skincare for edema and itchy skin

7. Mouth care

Why is it important to do mouthcare for patients with kidney issues

Because ammonia may not be properly excreted and can damage the mucousal membrane (inflammation)

Who is more susceptible to kidney injuries

1. Older adults (organs not working as well)

2. Indigenous people with DM

CKD staging

1. 90 and above is good

2. As GFR decrease, stage is progressively getting worse

Signs and symptoms of a kidney injury

1. Uremia and polyuria

2. Decreased GFR, increased BUN and creatinine

3. Nitrogenous waste buildup

4. Altered carb metabolism (hyperglycemia)

5. Increased triglycerides (risk if htn, stroke, MI, cvd)

6. Anemia and bleeding tendencies (platelet dysfunction)

7. Infection risk (altered immune response)

8. Fluid retention ( (HTN,HF, pulmonary edema, dyspnea)

9. GI and neurological issues

10. Bone issues

11. Pruritis

Kidney injury uremia

1. Uria is waste production from protein breakdown, when it’s not excreted properly it can build up

2. Get N/V, fatigue, cramps seizure, death

3. Often leads to dialysis

Kidney injury polyuria

Occurs in early stages, urine is not concreted/filtered properly

Kidney injury hyperglycaemia

Often results from altered carb metabolism

Kidney injury diagnostic testing

1. History and physical

2. Blood work (BUN, serum creatinine, eGRF, electrolytes)

3. Urine protein to creatinine ratio (early protein is associated with unfavorable long term outcomes) use first morning void specimen

4. Renal ultrasound (rule out obstruction and note size of kidneys)

Chronic kidney disease-mineral and bone disorder

Limit P, give phosphate binders and vitamin d supplements

Med that treats dylipidemia from kidney injury

Statins

Complications of kidney injury drug therapy

Digoxin, oral glycemic agents, antibiotics, opioids

What med should you avoid with a kidney injury

NSAIDs, use Tylenol instead

Kidney injury nutritional therapy

1. Protein restriction

2. Na and fluid restriction

3. Potassium restriction

4. Phosphate restriction

Kidney injury nursing care

1. Head to toe assessment (signs of fluid overload and electrolyte imbalances)

2. Daily weight

3. Vital signs

4. Nutrition (dietician)

5. Education (treatment options)

6. Respect patients choice

Hemodialysis

1. Filters blood, acts as an artificial kidney, blood goes back in body

2. 3-5 hrs 3 times a week

3. Exhausting, lifelong treatment

4. Vascular access

Hemodialysis AVF (arteriovenous fistula)

1. Joins artery to vein

2. Takes 4-6 weeks (prefer 3 months) to mature and be ready to use

3. Check patency (bruit, palpable thrill)

4. Avoid BP, BW, IV and injections into arm (could rupture)

Dialysis and meds

Hold meds before dialysis because they can be filtered out, give once dialysis is done

Why are patients on dialysis at risk of hypotension?

Because it causes a massive fluid shift

Peritoneal dialysis

1. 4+ exchange every day

2. Warmed to body temp Assess weight pre/post op

3. Moniter PD out (clear, light yellow, amount should be equal or exceed dialy sate)

Peritoneal dialysis pro

Fewer dietary restrictions, greater mobility, can be done at home

Peritoneal dialysis con

Greater risk of infection/peritonitis

Urinary tract calculi recurrence

50% experience recurrence

What is a urinary tract calculi

Accumulation of mineral salts

Urinary tract calculi calcium based stones

Most common type

Urinary tract calculi uric acid stones

May be from lack of fluid, increase of purine (animal protein), also associated with gout

Urinary tract calculi crystine stones

From increased amino acid, may be hereditary

Urinary tract calculi struvite stones

From UTISs or infectious stones

Signs and symptoms of a urinary tract calculi

1. Depends on place of obstruction

2. Abdominal pain (severe)

3. Hematurua

4. Renal colic (sudden acute pain in area of obstruction)

5. Nausea and vomiting

6. Cool, moist skin

7. Fever and chills (sign of infection)

Urinary tract calculi diagnostic testing

1. Urinalysis

2. Urine culture

3. Retrograde pyelography (dye and x ray to see stone location can be done during cystoscopy)

4. Cystocopy

5. X ray (KUB-kidney, ureter, bladder)

6. Blood work (renal function-BUN, creatinine)

Cystoscopy

1. Direct visualization of bladder by cystoscope (endoscopic test). Helpful for removal of large stones

2. May need meds to prevent bladder spasms

3. Drink fluids post procedure

4. Monitor voiding

5. If having a retrograde pyelography dye is inserted into a catheter and x rays are taken

Cystoscopy using general anesthesia

May be NPO before

Cystoscopy using local anaesthesia

encourage fluids (may need to flush out dye)

Interprofessional and nursing care of urinary tract calculi

1. Pain control (opioids)

2. Treat infection

3. Evaluate cause and prevent development (stones are often reoccurring)

4. Nutritional therapy (prevent new stones, adequate fluid)

5. Lithotripsy

6. Surgical therapy (incision and tube to remove stone)

7. Strain urine

Lithotripsy

Preferred method for breaking up kidney stones, minimally invasive

Shock waves break up the stone into smaller pieces that can be passed