renal disorders

Renal Disorders

Abnormal Urination

  • Frequency: Increased need to urinate.

  • Nocturia: Urination at night.

  • Urgency: Sudden strong need to urinate.

  • Dysuria: Pain or discomfort during urination.

  • Hesitancy: Difficulty in initiating urination.

  • Enuresis: Involuntary urination, particularly in children.

  • Urinary Incontinence:
      - Acute: Sudden onset, often due to temporary issues.
      - Chronic: Long-term incontinence often linked to various disorders.

  • Retention: Inability to completely empty the bladder, which can lead to discomfort.

Physical Characteristics of Urine

Color Variations

  • Bleeding (Hematuria): Presence of blood, indicating possible infection or injury.

  • Medications: Certain medications may alter urine color.

Clarity

  • Normal Clarity: Urine should be clear or translucent.

  • Cloudiness Concerns:
      - If urine is cloudy when freshly voided, it may indicate the presence of:
        - RBC: Red blood cells.
        - WBC: White blood cells.
        - Bacteria or pus (Pyuria).

Odor

  • Normal Odor: Typically aromatic.

  • Bacterial Decomposition: Can cause a more pungent smell.

Specific Gravity

  • Indicates Renal Function: Measures the kidney’s ability to concentrate urine.

pH

  • Influences of Diet:
      - Acidic: Lemon water, cranberry juice, high protein foods.
      - Alkaline: Dairy products, vegetables (legumes).

Constituents

  • Composed of:
      - Urea
      - Water
      - Electrolytes

Drugs That Cause Urine Color Changes

  • Anticoagulants: Can cause urine to appear red.

  • Diuretics: Lighten urine to a pale yellow color.

  • Pyridium: Results in orange or orange-red colored urine.

  • B-complex Vitamins: Produce a bright yellow color.

  • Levodopa & Injectable Iron Compounds: May cause brown or black urine.

Normal Laboratory Results (Serum)

Blood Urea Nitrogen (BUN)

  • Purpose: Identifies presence of renal problems by measuring urea, an end product of protein metabolism.

  • Normal Range: 10-20 mg/dl for adults.

  • Increased levels: Indicative of renal disease and dehydration.

  • Decreased levels: Associated with overhydration.

  • Affected by factors such as:
      - Increased dietary protein.
      - Muscle-wasting conditions.
      - Decreased blood flow or obstruction of urine outflow.

Creatinine

  • Purpose: Determinant of renal function produced by muscles in relatively constant quantities.

  • Normal Ranges:
      - Female: 0.5-1.1 mg/dl
      - Male: 0.6-1.2 mg/dl

  • Increased Levels: Associated with conditions like pyelonephritis.

  • Decreased Levels: Reflect decreased muscle mass.

  • Testing Recommendations:
      - Preferably NPO 8 hours before testing.
      - Avoid meat day before the test.
      - Ensure adequate hydration.

Other Types of Urine Testing

  • **Urinalysis (“Clean Catch”).

  • Urine culture (“Clean Catch”).

  • Sterile (Catheterization):** Normal residual volume 50-100 mL.

  • Bladder Scanning: Evaluates complete emptying; may be affected by bladder outlet obstruction (e.g., enlarged prostate) or loss of bladder muscle tone.

Urinary Retention

  • Description: Bladder distension leading to feelings of fullness.
      - May void frequent small amounts (<50 mL).
      - Often results in pelvic discomfort and abdominal distention.
      - Decreased urinary output.

Signs and Symptoms of Urinary Retention

  • Common Symptoms Include:
      - Pressure in the bladder.
      - Discomfort or pain.
      - Restlessness.
      - Diaphoresis (sweating).
      - Post-void residual (PVR) > 100 cc.

Causes of Urinary Retention

  • Medical Causes:
      - Anesthesia.
      - Surgical procedures.
      - Obstructions (e.g., enlarged prostate, strictures).
      - Childbirth.

  • Medication: Antihistamines can contribute.

  • Other Factors:
      - Kidney stones.
      - Removal of indwelling catheter.
      - Sexually transmitted infections (STIs).
      - Constipation.
      - Sacral nerve damage.

Nursing Care for Urinary Retention

  • Interventions:
      - Provide privacy and time for bladder emptying.
      - Assist with regular toileting.
      - Encourage water running, which may stimulate the reflex bladder.
      - Apply cold compresses to the abdomen.
      - Use Crede’s Method (applying pressure).
      - Encourage squatting or leaning forward to help voiding.
      - Utilize urinary catheters if indicated.
      - Administer cholinergic drugs to stimulate bladder contractions.
      - Monitor for bladder distention through palpation and percussion.

Urinary Tract Infections (UTI)

  • Definition: Infections affecting the urinary tract, categorized based on location and severity.

Catheter-Associated Urinary Tract Infections (CAUTIs)

  • Prevalence: Account for 31% of healthcare-associated infections (HAIs).

Types of UTIs

  • Upper UTI: Involving renal parenchyma, pelvis, or ureters, typically manifests with fever, chills, flank pain (CVA tenderness).

  • Lower UTI: Lacks systemic manifestations, characterized by specific signs and symptoms detailed in subsequent sections.

  • Pyelonephritis: Inflammation, usually related to infection, of the renal parenchyma and collecting system.

  • Cystitis: Inflammation of the bladder wall.

  • Urosepsis: UTI that has spread to systemic circulation; considered life-threatening.

Factors Increasing Urinary Stasis

  • Common Contributors:
      - Neurogenic bladder.
      - Presence of foreign bodies.
      - Kidney stones.
      - Anatomical factors, especially in females.

  • Compromising Immune Response:
      - Aging, diabetes mellitus.
      - Functional disorders, constipation.

  • Additional Risk Factors:
      - Pregnancy, poor hygiene, habitual delay in urination (often referred to as “nurse’s bladder”).

Clinical Manifestations

  • Lower Urinary Tract Symptoms (LUTS):
      - Bladder “Emptying” Symptoms:
        - Hesitancy, intermittency, post-void dribbling, urinary retention/incomplete emptying, dysuria.
      - Bladder “Storage” Symptoms:
        - Urinary frequency, urgency, incontinence, nocturia, nocturnal enuresis.

UTIs in Women

  • Prevalence: Most common bacterial infection among women, often caused by gram-negative bacteria, with E. coli being the most frequently isolated organism.

UTIs in Older Adults

  • Presentation: May not show classic symptoms and can present with non-localized abdominal discomfort, cognitive impairment, or generalized clinical deterioration.

Diagnosis of UTI

  • Goal: To confirm bacteriuria and pyuria.

  • Urinalysis:
      - First Step: Quick dipstick tests for nitrites (indicating bacteriuria) and WBC (indicating pyuria).
      - Further Confirmation: Microscopic urinalysis.

Urine Culture

  • When Performed:
      - If the UTI is complicated, nosocomial, frequent, unresponsive to treatment, or if the diagnosis is questionable.

UTI Risk Factor Reduction

Patient Education for Prevention

  • Key Practices:
      - Regularly and completely emptying the bladder.
      - Proper hygiene: Wipe perineal area from front to back after urination/bowel movements.
      - Adequate fluid intake: Recommend 2-3 liters daily.
      - Consideration of cranberry juice or essence; however, studies indicate little evidence of improved UTI outcomes, but it may inhibit uropathogen adherence to uroepithelial cells.
      - Advise sexually active females to urinate before and after intercourse.

Nosocomial/HAI UTI Risk Factor Reduction

  • Minimization Strategies:
      - Avoid catheterization or ensure early removal when possible.
      - Use aseptic techniques during urinary tract instrumentation.
      - Emphasize excellent hand hygiene and gloving during perineal care.
      - Strategies to prevent incontinence episodes.

Urinary Catheters Nursing Care

  • Key Responsibilities:
      - Ensure urine is flowing into the collection bag without obstruction.
      - Keep catheter tubing free of twists or kinks.
      - Position urine collection bag below the bladder level.
      - Avoid dragging or pulling on the catheter.
      - Monitor the area around the catheter for signs of infection (pus, inflammation, tenderness).
      - Perform bi-daily cleaning with soap and water around the catheter area.
      - Avoid applying powder or lotion near the catheter.
      - When in bed, hang the collection bag to avoid pulling.

CAUTI Prevention

  • Prevention Steps:
      - Use aseptic insertion techniques.
      - Train staff on catheter care and maintenance.
      - Implement care bundles aimed at clinical safety.

UTI Acute Interventions

  • Interventional Strategies:
      - Fluid Intake: Ensure adequate hydration unless contraindicated - water preferred; avoid irritants like caffeine, alcohol, and certain juices.
      - Pain Relief: Utilize warm baths or local heat application.

Antimicrobial Therapy

  • Protocol: Follow pathophysiological guidelines to address infection.

  • Patient Education:
      - Importance of completing the full course of antibiotics.
      - Seek follow-up care if symptoms do not resolve post-treatment.
      - Acknowledge that recurrence may occur within 1-2 weeks if treatment is inadequate.

Pyelonephritis

  • Overview: Infection of the renal collecting system with potential systemic implications.

Clinical Manifestations and Diagnosis

  • Symptoms: Can range significantly from mild fatigue to sudden chills, fever, vomiting, and flank pain (CVA tenderness).

  • Diagnostic Tests:
      - Refer to protocols established for UTI diagnostics.
      - Monitor additional WBC differentials, and utilize imaging studies as necessary.
      - Conduct blood cultures if bacteremia or urosepsis is suspected.

Costovertebral Angle Tenderness

  • Assessment Location: Flank area corresponding to the kidneys for tenderness evaluation.

Collaborative Care for Pyelonephritis

Mild Symptoms

  • Outpatient Management Recommendations:
      - Ensure adequate fluid intake.
      - Administer NSAIDs or antipyretic medications.
      - Schedule follow-up urine cultures and imaging studies.
      - Start on broad-spectrum antibiotics, adjusting to sensitivity when cultures become available with a treatment duration of 14-21 days.

Severe Symptoms

  • Hospitalization Management:
      - Restoration of fluid intake (initially parenteral, transitioning to oral after control of nausea or vomiting).
      - Administer NSAIDs or antipyretic drugs as indicated.
      - Follow-up with urine cultures and imaging studies.
      - Initiate parenteral antibiotics, transitioning to oral therapy once tolerable.

Nephrolithiasis (Kidney Stones)

Overview

  • Prevalence: 13% of men and 7% of women in the U.S. experience kidney stones.

  • Terminology:
      - Calculus: Refers to the stone.
      - Lithiasis: Refers to stone formation.

  • Demographics: Most commonly observed in middle-aged adults, with age correlating with increased risk for stone formation.

Diagnostic Studies

  • Methods:
      - Careful history and physical examination (H&P).
      - Non-contrast spiral CT (CT/KUB): recognized gold standard.
      - Ultrasound.
      - Intravenous pyelogram (IVP).
      - Urinalysis (examining for hematuria, crystalluria, and pH).
      - Retrieval and analysis of passed stones.

Five Major Categories of Kidney Stones

  • Calcium Oxalate: Most common type of stone.

  • Calcium Phosphate.

  • Uric Acid.

  • Cystine.

  • Struvite (Magnesium Ammonium Phosphate): Usually associated with infections.

Collaborative Care for Kidney Stones

Management of Acute Attack

  • Symptom Management:
      - Primarily for flank pain; recognized as one of the strongest sensations of pain.
      - Recommended pain management includes NSAIDs and opioids.

  • Additional Symptoms: Manage nausea and vomiting as needed.
      - Administer systemic antibiotics for concurrent infections.
      - Stones smaller than 4mm may pass spontaneously.
      - Stones larger than 4mm usually require stent placement or surgical removal.

Evaluation and Preventative Care

  • Stone Formation Causes: Evaluate to prevent future occurrences.

  • Patient Education:
      - Emphasize the importance of adequate hydration.
      - Guide dietary changes tailored to the composition of stones being passed:
        - Low Oxalate: Limit dark roughage, spinach, cocoa, nuts, etc.
        - Low Calcium: Controversial; recent evidence suggests dietary calcium might not contribute to stone formation.
        - Low Purine: Important for uric acid stones.

Endourologic Procedures: Lithotripsy

  • Types:
      - Outpatient Procedure: Disintegrates/pulverizes stones using shock waves.
        - Approach Options:
          - Internal (Direct): Cystoscopic or percutaneous approaches.
          - Laser Methods.
      - External (Indirect): Stones are broken down and washed out; provides a non-invasive option.
      - Complications: Potential risks include hemorrhage, infection, and retention of stone fragments post-procedure.

Lithotripsy Post-Procedure Care

  • Common Outcome: Hematuria is a frequent occurrence after the procedure.

  • Stenting: Typically placed to aid in the passage of stone fragments and removed after 1-2 weeks.

Nephrostomy Tube

  • Indication: When ureter is fully obstructed for any reason.

  • Procedure: Surgically inserted into the renal pelvis via a small flank incision; attached to an external drainage bag as a temporary solution.
      - Monitoring for Complications: Excessive pain or drainage around the exit site may indicate blockage.

  • Irrigation Protocol: Strict aseptic technique is crucial; if irrigation is ordered, instill gently no more than 5 mL of sterile normal saline (NS).

Nursing Considerations for Kidney Stones

Nursing Implementation Goals

  • Patient Education: Focus on reducing risk factors through lifestyle modifications and dietary changes appropriate to the type of stones.
      - Fluid Intake: Encourage 3 L per day to dilute urine and prevent stone formation.
      - Care for Obstructed Stones: During obstruction episodes, excess fluid intake is contraindicated, as no evidence supports its efficacy.
      - Preferred Beverage: Water is recommended as the main source of hydration.

Nursing Implementation Continued: Risk Factor Reduction

  • Sedentary/Immobilized Patients: Encourage adequate fluid intake.
      - Implement regular position changes every 2 hours.
      - Suggest patients stand or sit to void bladder regularly.
      - Promote ambulation whenever possible.

  • Monitoring:
      - Assess and monitor the passage of stones through filtering all urine with gauze or other filtering methods.

Controlling Pain

  • Pain Management Challenges: Pain from kidney stones can be difficult to manage.
      - PCA (Patient-Controlled Analgesia) pumps are often implemented.
      - Explore additional non-pharmacological methods to alleviate pain.

Urinary Diversions

Overview

  • Definition: Surgical procedures creating alternative pathways for urine excretion when the bladder is dysfunctional or removed.
      - Incontinent Diversions: Require external devices to collect urine.
      - Continent Diversions: Create internal reservoirs for urine storage with potential for self-catheterization.

Types of Urinary Diversions

  • Ileal Conduit:
      - Incontinent diversion composed of a small piece of bowel used to transport urine to the skin surface.

  • Continent Cutaneous Reservoirs:
      - Reservoir created using a segment of bowel allowing for intermittent catheterization without external appliances.

  • Orthotopic Neobladder:
      - Internal reservoir created from a segment of intestine that connects to the native urethra; approximates normal voiding functions.

Urinary Diversion Surgical Procedure

Preoperative Management

  • Focus Areas: Address patient’s anxiety, fears, and teaching needs regarding postoperative care.
      - Involve wound, ostomy, and continence nurses for comprehensive care planning.

Postoperative Management

  • Immediate Care Protocols: NPO (nothing by mouth) and NG (nasogastric) tube may be indicated.
      - Patient Teaching for Ileal Conduit:
        - Ensure the appliance fits well and practice meticulous skin care.
        - Expect mucus presence in urine.
        - Regular stomal assessments are necessary.
      - Patient Teaching for Continent Diversions:
        - Cath every few hours at first, extending to every 4-6 hours over time.
        - Learn to void by relaxing the sphincter and applying downward pressure; the urge to void may not be felt initially.
        - Practice pelvic floor relaxation techniques.