WK4 - Elim 1 STUDY GUIDE ANSWERS ANSERR
Concept Map for Urinary Elimination
Definition:
Urinary elimination is the excretion of waste products through the process of expelling urine, also known as micturition.
This means the body is getting rid of liquid waste (liquid trash) to maintain a clean internal environment.
[Source: Giddens, p. 164]
Scope:
The concept ranges from normal formation and excretion of waste to severe impairment of these processes.
It can be conceptualized as a continuum from “perfectly working” to “total failure.”
[Source: Giddens, p. 164]
Normal Physiologic Process:
Involves urine formation occurring in renal nephrons through:
Glomerular filtration
Tubular reabsorption
Tubular secretion
Urine is excreted through the ureters, bladder, and urethra.
The kidneys filter blood, reclaim essential substances, and eliminate waste, sending excess liquid to the bladder.
[Source: Giddens, pp. 164-165]
Risk Factors:
Primary risks include:
Advanced age
Altered cognition
Impaired mobility
Medications such as anticholinergics
Older age and certain medications can impair the body’s ability to control or initiate urine flow.
[Source: Giddens, pp. 168-169]
Assessment:
Assessment methods include:
History of urinary patterns
Physical exam:
Inspecting for bladder distention
Palpating the bladder
Diagnostics:
Urinalysis
Creatinine and BUN tests
Ultrasound
Nurses utilize visual examination, tactile assessment, and laboratory tests to assess kidney function and urinary system status.
[Source: Giddens, pp. 169-170]
Clinical Management:
Primary prevention strategies include:
Maintaining hydration
Regular toileting habits
Collaborative care may involve:
Catheters
Diuretics
Dialysis
Adequate hydration aids in maintaining regular urinary function while interventions can support impaired systems.
[Source: Giddens, pp. 170-172]
Interrelated Concepts:
Linked to:
Nutrition: Ingested fluids and foods affect urine quantity and composition.
Fluid and Electrolyte Balance: The kidneys regulate water and electrolyte levels, maintaining homeostasis.
Acid-Base Balance: The kidneys help control blood pH by excreting hydrogen ions and reabsorbing bicarbonate.
Mobility: Physical capability affects an individual's ability to respond to urinary needs.
Cognition: Cognitive functions influence the ability to recognize the need to eliminate and respond appropriately.
[Source: Giddens, pp. 172-173]
Interrelated Concepts Specific Relationships
Fluid and Electrolytes:
Kidneys maintain homeostasis by controlling the retention or elimination of water and electrolytes under hormonal influence.
The kidneys act like a dam, retaining water when the body is dehydrated and releasing it when overhydrated.
[Source: Giddens, p. 173]
Acid-Base Balance:
The kidneys also function as a third line of defense against pH imbalance by excreting hydrogen ions and reabsorbing excess bicarbonate.
When blood becomes too acidic, kidneys eliminate acid through urine to sustain life.
[Source: Ignatavicius, p. 275]
Nutrition:
Fluid intake and dietary composition directly influence urine production and composition.
Food and drink serve as the primary substrates the kidneys process for waste removal.
[Source: Giddens, p. 173]
Essential Kidney Functions for Homeostasis
Excretion of Waste:
Removal of metabolic toxins and nitrogenous wastes (such as urea) from the bloodstream.
Critical for preventing accumulation of harmful substances.
[Source: Giddens, p. 164; Iggy, p. 1454]
Fluid Balance Regulation:
Regulation of water volume in the body through filtration and reabsorption processes.
Acts similarly to a sponge, maintaining appropriate body water levels.
[Source: Giddens, p. 165; Iggy, p. 1454]
Electrolyte Balance:
Regulation of sodium, potassium, and calcium levels in the body, pivotal for muscle and heart function.
Maintains a delicate balance crucial for various physiological functions.
[Source: Giddens, p. 165; Iggy, p. 1454]
Acid-Base Balance:
Control of blood pH by managing bicarbonate and forming excess acids/ammonium for excretion.
Maintaining optimal blood pH is vital for organ functionality.
[Source: Ignatavicius, pp. 275, 1454]
Hormone Secretion:
Production of essential hormones like erythropoietin for RBC production and renin for blood pressure management.
Endocrine signaling helps regulate blood functions.
[Source: Giddens, p. 165; Iggy, pp.1439, 1454]
Metabolic Waste Clearance:
Complete filtration of creatinine and urea through the kidneys, providing measurable indicators of renal function.
Kidney's effectiveness as the body's waste-cleansing system is vital for health monitoring.
[Source: Giddens, p. 170; Iggy, p. 1455]
Plan of Care for Acute Kidney Injury (AKI)
Fluid Resuscitation or Restriction:
Administer IV fluid boluses for pre-renal AKI or strictly limit fluid intake if the patient is in the oliguric phase.
Rationale: If dehydration is the cause, fluids are necessary; if kidneys fail, limiting intake prevents internal drowning.
[Source: Iggy, p. 1461]
Pharmacological Management:
Administer diuretics (Furosemide) to stimulate urine output and CAD medication (like calcium channel blockers) to stabilize blood pressure.
Rationale: These medications help revive kidney function and manage renal blood flow.
[Source: Iggy, p. 1461]
Electrolyte Monitoring:
Constantly assess for hyperkalemia using serum potassium levels and utilize sodium polystyrene sulfonate if levels become elevated.
Rationale: High potassium levels can induce cardiac events; medications help to remove excess through the gastrointestinal tract.
[Source: Iggy, p. 1461]
Nutritional Therapy:
Implement a diet low in protein, sodium, and potassium, while providing enough non-protein calories to avert catabolism.
Rationale: Reducing waste load on the kidneys while supplying energy for healing is necessary.
[Source: Iggy, p. 1462]
Renal Replacement Therapy:
Prepare the patient for dialysis or CRRT if metabolic acidosis or fluid overload presents a severe risk.
Rationale: If kidney functions halt completely, dialysis is critical to filtration.
[Source: Iggy, p. 1462]
Plan of Care for Acute Glomerulonephritis (AGN)
Infection Control:
Administer prescribed antibiotics (e.g., Penicillin) for infections, especially post-Streptococcus.
Rationale: AGN is a common sequela from infections; we must eradicate the original pathology.
[Source: Iggy, p. 1440]
Edema Management:
Monitor daily weights, and limit sodium and water intake to manage systemic swelling and hypertension.
Rationale: Reduced dietary load decreases the burden on impaired kidneys and lowers blood pressure.
[Source: Iggy, p. 1440]
Uremia Assessment:
Look for signs of “uremic frost” and provide care for pruritus to enhance patient comfort.
Rationale: Waste accumulation can cause itchiness; management of skin conditions is crucial.
[Source: Iggy, p. 1441]
Rest and Energy Conservation:
Coordinate nursing care to ensure frequent rest periods due to systemic inflammation-related fatigue.
Rationale: Fatigue is a product of internal inflammatory response mechanisms that require energy conservation.
[Source: Iggy, p. 1440]
Interdisciplinary Coordination:
Work with dietitians to adjust protein intake based on BUN and creatinine levels.
Rationale: Tailoring protein levels according to waste production helps mitigate toxicity levels.
[Source: Iggy, p. 1441]
Priority Problems for Acute Glomerulonephritis (AGN)
Fluid Volume Excess (Fluid Overload):
Intervention: Assess for pulmonary crackles, neck vein distention, and abnormal heart sounds every shift.
Rationale: Monitoring physical signs of fluid retention aids in early intervention for pulmonary edema.
[Source: Iggy, p. 1440]
Risk for Impaired Skin Integrity:
Intervention: Inspect the skin for color changes, lesions, or excoriation due to pruritus.
Rationale: Effective skin inspections identify early signs of damage and prevent infection opportunities caused by scratching.
[Source: Iggy, p. 1441]
Potential for Reduced Kidney Perfusion (Hypertension):
Intervention: Daily blood pressure monitoring, notifying providers of significant deviations.
Rationale: Detecting hypertension can help avert further damage to the glomeruli.
[Source: Iggy, p. 1440]
Laboratory Indicators
Elevated Serum Creatinine and BUN:
Lab results reflecting levels above normal for BUN and creatinine indicate renal insufficiency.
Both substances should be eliminated via urine; high levels can signify impaired kidney function.
[Source: Alfaro, p. 85]
Priority Problems for Acute Kidney Injury (AKI)
Electrolyte Imbalance (Hyperkalemia):
Intervention: Continuously monitor serum potassium levels and report values over 5.0 mEq/L immediately.
Rationale: High potassium can lead to cardiac dysrhythmias; urgent monitoring helps save lives.
[Source: Iggy, pp. 1441, 1460]
Impaired Acid-Base Balance (Metabolic Acidosis):
Intervention: Watch for Kussmaul respirations and assess arterial blood pH.
Rationale: Identifying acidosis can help prompt timely interventions and correct dangerous pH levels.
[Source: Iggy, pp. 1441, 1454]
Risk for Infection:
Intervention: Execute meticulous care for dialysis catheter sites using sterile technique.
Rationale: Patients with AKI are more susceptible to infections; prevention is key.
[Source: Iggy, pp. 1454, 1462]
Prioritization Principles in Renal Nursing Care
Acute vs. Chronic:
Prioritizing patients with sudden drops in urine output (Acute) before stable long-term dialysis patients (Chronic).
Acute changes pose immediate threats relative to long-term stable conditions.
[Source: Alfaro, p. 83]
Stable vs. Unstable:
Prioritize unstable renal patients with dropping blood pressure and rising heart rate over stable patients with abnormal labs.
Unstable patients require immediate attention to prevent further harm.
[Source: Alfaro, p. 83]
Urgent vs. Non-urgent:
Administer urgent medications for potassium levels (e.g., 6.5 mEq/L) before routine assessments on stable patients.
Urgent care addresses potentially life-threatening situations, ensuring patient safety.
[Source: Alfaro, p. 84]
Actual vs. Potential:
Treat patients with acute breathing issues due to fluid before hanging IV fluids for at-risk patients.
Real-time actual needs should be prioritized over presumptive potential problems.
[Source: Alfaro, p. 84]
Patient Safety Risks Due to Altered Elimination
Circulatory Overload and Heart Failure:
Fluid retention from reduced kidney function can cause pulmonary edema, leading to heart failure.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Life-Threatening Hyperkalemia:
Impaired potassium elimination may lead to fatal serum levels exceeding 5.0 mEq/L, posing a severe cardiac risk.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Metabolic Acidosis:
Inability to regulate acid-base balance increases risk for dangerously low blood pH.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Uremic Syndrome (Azotemia):
Nitrogenous waste buildup can negatively affect multiple body systems and manifest as cognitive issues.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Falls and Skin Breakdown:
Urgency in elimination may cause falls, and incontinence causes skin damage from waste buildup.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Consequences of Ignoring Safety Risks
Delayed Recognition of Clinical Deterioration:
Failing to recognize cues can result in AKI progression to irreversible damage.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Fatal Cardiac Dysrhythmias:
Lack of potassium retention knowledge can lead to missed monitoring and potential cardiac arrest.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Respiratory Failure:
Ignoring fluid overload indicators can result in a patient unable to oxygenate adequately.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Medications Increasing AKI Risks
NSAIDs:
Common non-steroidal medications like Ibuprofen and Aspirin can impair blood flow to kidneys, risking AKI development.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Nephrotoxic Antibiotics:
Some antibiotics, particularly Aminoglycosides, can be directly cytotoxic to kidney tissues.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Iodinated Contrast Media:
High-osmolarity contrast used in imaging tests poses a risk of Contrast-Induced Nephropathy.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Chemotherapy Agents:
Certain chemotherapy drugs can inadvertently damage kidney tissues.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Medications for Treating AKI/AGN
Diuretics (Furosemide [Lasix], Bumetanide [Bumex]):
Used to promote fluid and electrolyte excretion.
Nursing Intervention: Monitor intake/output and blood pressure closely.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Antibiotics (Penicillin, Erythromycin, Azithromycin):
Administered for underlying infections in AGN. Nursing Intervention: Assess for allergies; complete the course to prevent recurrence.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Immunosuppressants (Corticosteroids, Cytotoxic Drugs):
Used to control excessive immune reactions in AGN. Nursing Intervention: Monitor for signs of new infections due to immunosuppressive effects.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Potassium-Lowering Agents (Sodium Polystyrene Sulfonate):
These medications facilitate the removal of excess potassium via the intestines. Nursing Intervention: Monitor for effective bowel movements, as the drug must be eliminated.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Nursing Interventions for Administering Diuretics
Hourly Urine Output Monitoring:
Measure urine output hourly, ensuring the effectiveness of the diuretic.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Daily Weight Measurement:
Weigh the patient at the same time daily to track fluid loss effectively.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Electrolyte Surveillance:
Closely monitor potassium and sodium levels post-diuretic administration.
[Source: Ignatavicius 11th ed., Ch. 59-60]
Blood Pressure and MAP Assessment:
Regularly assess blood pressure and maintain a MAP above 65 mm Hg, ensuring adequate renal perfusion.
[Source: Ignatavicius 11th ed., Ch. 59-60]
AKI vs. AGN Comparison
Risk Factors:
AKI: Hypovolemia, nephrotoxins, cardiac disease, obstructive processes.
AGN: Recent infections (especially Streptococci), systemic conditions like Lupus.
One-liner: AKI is often due to immediate physical/chemical stress; AGN results from infectious or autoimmune triggers.
Clinical Manifestations:
AKI: Shows oliguria, edema, crackles, increasing creatinine levels.
AGN: Presents as hematuria, proteinuria, and periorbital edema.
One-liner: AKI leads to a sharp decline in urine output, while AGN features blood and proteins leaking into urine.
Potential Complications:
AKI: Can progress to chronic kidney disease (CKD), heart failure, severe hyperkalemia.
AGN: May result in acute hypertension and pulmonary edema.
One-liner: AKI risks permanent dysfunction while AGN may result in critical hypertensive elevations.
Treatment:
AKI: Focuses on fluid resuscitation, diuretics, potential dialysis.
AGN: Antibiotic therapy to eradicate infection and corticosteroids for inflammation.
One-liner: AKI treatment aims to restore renal perfusion; AGN treatment centers around infection control and immune modulation.
Nutritional Considerations for AKI vs. AGN
AKI Nutrition: High-calorie intake is necessary to prevent muscle breakdown while being strictly low in protein, sodium, and potassium.
AGN Nutrition: Sodium and fluid restrictions as needed; limited protein only when BUN levels are critically high.
One-liner: AKI requires high calories and low protein; AGN emphasizes low sodium to control blood pressure while allowing more protein unless toxic levels arise.
Types of Acute Kidney Injury
Prerenal AKI:
Due to reduced kidney perfusion. Example causes include dehydration and heart failure.
Intrinsic (Intrarenal) AKI:
Direct renal tissue damage caused by nephrotoxins or inflammatory responses.
Postrenal AKI:
Results from obstructions in urine flow from kidney stones or tumors.
One-liner: AKI is classified according to where the dysfunction occurs: before, within, or after the kidneys.