week 2 altered urinary elimination 
Week 2 Altered Urinary Elimination
Function of the Renal System: Filtration, Reabsorption, Vit D, Fluid regulation, RBC formation, blood pressure regulation and Acid base balance.
Important FACTS to remember
The kidney eliminates Creatine and urine VERY Well so when BUN and Creatine are HIGH this is called Azotenima.
The Kidney Production of Erthypotina, so when the renal system is damaged, medication is needed to sublet the loss. (Epoetin Alfa)
Erythropoietin: given in help with red blood cell formation, but can cause hypertension. To check the BP before giving.
Urinary system: Store Urine
For Adults urine output by MIN is 0.5mL/kg/hr urine (Example a patient that is 45kg would release 23mL of urine.
Urine output in less than 30ml/hr (dehydration AKI… HOWEVER, do not wait till you see 30mL/hr be Proactive with patients' kidneys. Go based on the patient's weight!!!! Get you patients weight at the START of the Shift
Insulin is given to PUSH K+ back into the Cell, Calcium Gluconate to improve cardiac contractility. (for those EKG/Peaked P Waves you WILL See.)
Sodium Bicarb to correct Acidosis/shift K+ into the Cell. Sodium polystyrene Sulfonate/ Kayexalate given PO/Enema. REMOVES 1 mEq or K+ per 1g of Drug.
Physiology of urine formation, Glomerular Function: Blood is filtered by the hydrostatic pressure, Passes through the Bowman's Capsule.
The kidneys require over 20% of the total cardiac output to maintain an adequate blood flow of 1200 ml/minute. Urine is then sent through the ureters to the bladder, which has a capacity of 600 to 1,000 ml.
Glomerular filtrate passes down tubule, when we get the GFR which should be 125mL/min.
Effects of aging on the Urinary system: decreased renal blood flow, results in a decreased GFR. Changes in hormones can decrease the ability to concentrate urine and excretion of Na, K+ and Acid.
Between ages 30-90, the size of the kidney decreases 20% to 30%. By the 70s loss of 30% of GFR. Atherosclerosis accelerates decreases of renal size with age.
Testing and Diagnostic studies: UA: first void of the day is best, and within the hour of getting a sample.
Creatinine Clearance: collect a 24hrs sample, this test closely approximates GFR. over 1.2 Kidney Failure. Throw out the first sample.
BUN: which checks the amount of waste, also checks for Dehydration!!!
A Urodynamics: a Catheter insertion test.
Lithotripsy: is a procedure used to break up Kidney stones(laser), allowing them to pass
In BOTH AKI and CKD you will MOST likely see GFR is will go DOWN, BUN will go UP , Creatinine will go UP
Acute Kidney Injury: AKI Sudden
AKI- 3 things that can happen to the kidney to cause injury depends on the location,
3 locations:
Prenatal/The Heart- this happens when the heart has experienced some trauma, (Impaired Perfusion) like a MI, HF, or TIA, due to some kind of Ischemia. Hypovoemia, basically anything metabolic impairment and decreased renal blood flow to perfusion. Burns, GI issues, Hemorrhage, N&V.
Intrarenal/the kidney, This is caused by DIRECT trauma to the kidney. Like Medications (nephrotoxic injury). Damages to the renal parenchymal tissues, causes a malfunction in the nephrons… Infections, Glomerular lesion, Vascular lesions.
Postrenal/The bladder, Mechanical obstruction of outflow. Like PSA, BPH, Prostate cancer, Pelvis floor prolaps, its a RELUX INTO the renal pelvis. Only 10% of AKI cases.
UTI: Most common in women, and most common bacteria is E. Coli, Klebsiella, Pseudomonas, Staphylococcus group B, Candida albicans and Enterococcus.
Risk Factors: Age, obesity, HIV,
Uncomplicated infections occur in the normal urinary tract, usually involving bladder. Complicated: Coexists with presence of stone or obstruction, catheters, abnormal GU tract. Diabetes/neurologic diseases. Resistance to antibiotics immunocompromised, pregnancy-induced changes, recurrent infection.
Cystitis(LowerUTI): Caused by Inflamed Bladder or/and Urethra. Clinical Manifestations would be Burning, frequency, urgency, suprapubic pain, dysuria, hematuria, fever, cloudy/discolored urine, confusion in older adults.
Treatment: ABX bases of labs due to Bacritrim found on the C&S, Phenaxopridine- for pain AZO. Education on prevention, Wipe front to back, cotton underwear, void after sex, avoid too tight clothes and swim suits for too long.
Pyelonephritis/upper UTI: Caused by E.Coli. Kidney Infection, Purulent filled pelvis and calyces. Manifestations would be Flank pain, dysuria, pain at the costovertebral angles and other common UTI sxs.
DX and Treatment is the same: UA look for WBC in the urine, Nitrates. ABX for uncomplication UTI (Bactrim, Nifro, Fosomycin.) (Ampicillin, amoxicillin, or Cephalosporins.) are the treatment options for this and pain management.
Complication: Flurouinalones - CIPRO
Promote Fluid intake to 3L a daily, and do not HOLD your urine.
AKI: 3 Phases! Oliguric, diuretic, and recovery. “RIFLE”
Risk-First stage of AKI (min amount pt needs to Void in 6hrs)
Injury-Second Stage (urine output drops by 50%.during and after Sx, Hypotensive for too long)
Failure-Increases in severity (output drops to 75% in 24 hrs. Or Anuria in 72hrs. Creatinine 5.2, urine out/put of 10mL/hr)
Loss-Increase in severity (below 0.3mL/hr or haven’t peed in hrs-days)
End-Stage-renal diseases (Complete Renal Disease)
Oliguric manifestations and assessment (Seen in AKI)
Inspect risk for fluid volume excess, LOW Sodium, High potassium. Urine output in less than 30ml/hr (dehydration) HOWEVER, do not wait till you see 30mL/hr be Proactive with patients' kidneys.
Go based on the patients weight in kg and then multiple by 0.5mL
Watch out for signs of hyponatremia and hyperkalemia. Perform LOC neuro checks, due to the waste product accumulation. Infection, and metabolic acidosis, check ABG’ GFR will be Low, and Edema
Treatment for Oliguric:
The goal here is to stabilize the fluid volume overload, and fluid&electrolyte imbalances. Administer diuretics as needed but be cautious… Manage potassium levels will likely be high
Diuretic Stage Manifestations/assessment and treatment
In this stage we are actually watching for Fluid Deficit!!! So watch volume…the urine output increases up to 5 liters a day. That’s about 5000mL
(monitor for low BP) Watching for hyponatremia, hypokalemia and Hypovolemia, Hypotension….
Treatment Goal: is going to stable the fluid deficit and imbalance, IV fluids as ordered and watch for fluid Overload
Recovery Stage Manifestations/assessment and treatment
This is where the kidney should start showing signs of recovery, Lab trending back to normal limits. The goal is to maintain and educate patients to maintain urinary fluctuation if possible. Patients can develop CKD, if not fully recovered for AKI.
In some cases temp Dialysis can be needed. Monitor for complications, Electrolytes, K+ supper important, Follow fluid and diet restriction, follow up care if needed.
Chronic Kidney Diseases
Progressive, slow, irreversible loss of kidney function is more common.
Caused: by T2D (leading cause) in about 1 and 3 adults with T2D have CKD. T2D, Obesity, HTN, and CHF. Prevention is KEY: lower risk for these complications/Managing Diagnoses. Education on nephrotoxic drugs, Screenings, blood sugars, limit exposure. Sodium Bicarb for treatment, ARB for HTN.
Treatment: Sodium Bicarb, teach about family screenings, limit exposure to salt.
GFR has to be high for 3 months before its official DX. Watch for Hyperkalemia, confusion and anuria. Will see Peaked T waves on an EKG.
CKD: Stages GFR is less than 60
Polyuria is seen in CKD EARLY STAGE- this will dilute urine and cause anemia, fatigue and HTN.
END/LATE Stage: Kidney failure when GFR is under 50, will have Uremia (waste, toxics and blood in the urine) since kidneys are not filtering this out. SXS of Oliguria, Azotemia, Anemia, and Acidosis.
Treatment: Will Need Dialysis typically 3 days a week. Patients are at higher risk for infections, Heart Failure, Electrolyte retention(watch K+), anemia (Epoetin Alfa), Stomatitis, Anorexia, Seizures, LOC changes and Pruritus. Will Be on a Renal Diet: Low salt, Low K+ and Low Phosphorus. Atherosclerosis failures increase also….
CAUTI- Catheter acquired urinary tract infection (from foley)
HAI- Hospital Acquired Infection.
Insulin is given to PUSH K+ back into the Cell, & Calcium Gluconate to improve cardiac (EKG)
Dialysis types
Fistula is a surgical connection between an artery and a vein, typically placed in the arm, upper arm and wrist of the non-dominant arm. Sx is called Fistulotomy and takes 6 weeks to heal before use.
Peritoneal: Usually done on an outpatient/home basis, usually ordered due to patient preference. It can be done at home every night during sleep. 8-12hrs A catheter is put in via SX into the peritoneal cavity. The peritoneal membrane serves as the semipermeable membrane. Dialysate is drained from the Abd cavity via gravity and into the container.
Typically done in 3 phases. Inflow, Dwell, and Drain. (during Ultrafiltration/Fluid removal Dextrose is used as the Osmotic agent.) Hints the Hyperglycemia, and hypertriglyceridemia and long-term peritoneal membrane dysfunction.
Prep/During: Assess VS, lung sounds, fluid status, Inspect port Site, WARM Solution.
Compilations: are possible infection of the port (Peritonitis) will look cloudy/bloody pus, odor, redness, swelling and sxs of Hyperglycemia.
Hemodialysis: Usually done in outpatient at a special center or home. The patient's blood moves from an implanted shunt, fistula or catheter in the artery machine. Exchanges of waste, fluids and electrolytes. Clean blood is then filtered back into the body. Typically it takes 3-4hrs.
Complication: Infection of the AV Fistula/blood, Hypotension, and dizziness, Anemia. Infections SXS: yellow/green odor like pus, redness, swelling, warmth.
Good Dialysis Nursing Tips: Prior to a Dialysis session, check vitals, weight,(make sure weight patients in the same way/time EVERY TIME), and Labs. This will promote safety, DO NOT hold Insulin and HOLD ALL Antihypertensive and Diuretics meds. You NEED a good and high enough BP. Assess Fistula… Feel and hear for thrill and brute. Assess for Access for dialysis port.
Renal Diet: Low sodium, Low potassium (lettuce, cabbage, cucumbers, green beans), Low Protein diets (LEAN meats, Chicken breast, turkey, egg whites, LOW FAT GREEK Yogurt, Tofu)
Glomerulonephritis: Caused by Strep throat, 3rd leading cause of kidney diseases in the american. Acute and chronic Nephrotic drugs are the biggest cause also.
Treatment would be ABX… they are very strong. Dose is for 1-2 weeks, can form strep B infection if taken longer.
SXS: Headache, HTN, UTI SXS, Facial Edema, Low grade fever and weight gain. GFR will go down. Smokey urine - bleeding from the Urinary tract.
ASPGN: Acute Post Strep Glomerulonephritis: hold protein, Fluid and Sodium restrictions for Edema/Oliguria, rest to manage HTN and Renal Dysfunction.
Nephrotic Syndrome: Is a group of Kidney disorders causing the body to excrete excessive protein in the urine due to a Damaged Glomeruli, the tiny vessels in the nephrons that filter waste and excessive fluids. Proteinuria is greater than 5, the Albumin will be LOW
Causing: peripheral/leg swelling, Weight gain, HTN and HLD.
Polycystic Kidney Disease/PKD: Genetic- dominant gene- cyst filled with fluid may have blood or pus.
Manifestations: Develops at 30-40 years of age. Hard to touch during a palpation exam of the abd. NO CURE. Maybe a partial Nephrectomy could help. Best to get Genetic counseling/Screenings.
Renal Calculi/Nephrolithiasis/Kidney stone: Majority of american americans, Dehydration is the biggest causes, middle age, Risk and age.
Diet: Watch for Calcium in the diet (red meat, Tums, organ meat, fish, red wine).
Biggest SXS: FLANK and Abd Pain.
Treatment: First KUB, Stone analysis for DX. Pain meds, hydration, stent for removal, Laser (Lithotripsy). Stones of 4mm or less may pass. But more than 7 have to be removed.
Incontinence.
Overflow: Bladder unable to hold urine. Typically due to weak Pelvic muscles, nerve damage of enlarged prostate.
Stress incontinence: pelvic/floor muscles weakness, will urinate a little when patient coughs, laughs, and in pregnancy.
Urge: Infection, something is wrong with bladder Structure so it feels like you have to go when you don't have too. To Help with this: After peeing, Waiting 20-30 sec after while still sitting on the toilet