Elimination Concepts Priority concept for this chapter: Elimination Interrelated concepts: Fluid and electrolyte balance; Acid–base balance; Immunity; Pain Pyelonephritis Pathophysiology: bacterial infection that starts in the bladder and moves upward to infect the kidneys Acute vs chronic:Acute: active bacterial infection Chronic: repeated or continued upper urinary tract infections; almost exclusively in patients with anatomic urinary tract abnormalities Complications: abscesses can develop on kidneys Etiology and Genetic Risk (Pyelonephritis) Acute etiology: results from bacterial infection with or without obstruction or reflux Chronic etiology: usually with structural deformities, urinary stasis, obstruction, or reflux Common organisms: Escherichia coli or Enterococcus faecalis Incidence and Prevalence Most common in young females who are sexually active Common in the second trimester and beginning of the third trimester in pregnant females Recognize Cues: Assessment (Pyelonephritis) History: ask about recurrent UTIs, diabetes, stone disease, GU defects, reduced immunity, kidney function Imaging considerations: ensure woman is not pregnant before radiographic imaging Physical assessment/signs: inspect flanks and palpate costovertebral angle (CVA) for pain, edema, redness Psychosocial assessment: anxiety, embarrassment, guilt Key Features ACUTE PYELONEPHRITIS:Fever; Chills Tachycardia and tachypnea Flank, back, or loin pain Tenderness at CVA Abdominal, often colicky, discomfort CHRONIC PYELONEPHRITIS:Hypertension Inability to conserve sodium Decreased urine-concentrating ability, nocturia Tendency to develop hyperkalemia and acidosis Nausea and vomiting General malaise or fatigue Burning, urgency, or frequency of urination; nocturia Recent cystitis or treatment for UTI Recognize Cues: Assessment (Cont.) Laboratory assessment:Urinalysis Blood cultures WBC count with differential C-reactive protein ESR BUN, creatinine, GFR Imaging assessment: Other diagnostic assessment:Antibody-coated bacteria in urine Radionuclide renal scan Analyze Cues and Prioritize Hypotheses Priority collaborative problems:Pain (flank and abdominal) due to inflammation and infection Potential for chronic kidney disease (CKD) due to kidney tissue destruction Planning and Implementation Managing pain Nonsurgical management: Acetaminophen; antibiotics (IV usually) Catheter replacement Nutritional changes Surgical management: Pyelolithotomy; nephrectomy; ureteral diversion or reimplantation of the ureters Preventing CKD: Blood pressure control; nephrology referral Care Coordination and Transition Management Self-management education: drug regimen; adequate fluid intake; disease recurrence; coping mechanisms Health care resources: community outreach; interprofessional care Evaluate Outcomes Outcome indicators:Pain is controlled Patient is knowledgeable about disease, treatment, and interventions to prevent or reduce CKD progression Acute Glomerulonephritis Definitions:Primary: involve the kidneys primarily Secondary: kidney involvement is part of a systemic disorder Pathophysiology: develops suddenly from an excess immune response within kidney tissues Cause: usually infectious Recognize Cues: Assessment (Acute Glomerulonephritis) History: recent infections, illnesses, surgery, systemic diseases Physical assessment/signs: edema (facial, eyelids, hands); hypertension (fluid overload); dark urine; oliguria; dysuria Recognize Cues: Assessment (Cont.) Laboratory assessment:Urinalysis: hematuria, proteinuria 24-hour urine collection: total protein Serum albumin: decreased Serum creatinine: elevated BUN: elevated GFR: may be decreased Other diagnostic assessment:Kidney biopsy: precise diagnosis if needed Take Actions: Interventions (Acute Glomerulonephritis) Managing infection: appropriate antibiotic therapy; infection control Preventing complications: fluid and electrolyte balance; antihypertensive drugs Providing education: weight and blood pressure daily; drug regimen/side effects Chronic Glomerulonephritis Course: develops over years to decades Symptoms: mild proteinuria, hematuria, hypertension, fatigue, occasional edema Cause: exact cause not known Recognize Cues: Assessment (Chronic Glomerulonephritis) History: other health problems; recent infection; fatigue; elimination patterns Physical: systemic circulatory overload; lung crackles; uremic symptoms (slurred speech, ataxia, tremors) Psychosocial: uncertainty, loss, fear Diagnostic assessment (Chronic Glomerulonephritis) Urinalysis: protein GFR: decreased Serum creatinine: elevated BUN: elevated Sodium and phosphate levels ABGs: acidosis Imaging: kidney biopsy if needed Take Actions: Interventions (Chronic Glomerulonephritis) Slow progression and prevent complications Dietary changes; fluid intake; drug therapy Ultimately dialysis or transplantation Nephrotic Syndrome Pathophysiology: Glomerular permeability increases; allows larger molecules to pass into urine Consequences: massive loss of protein into urine, edema, decreased plasma albumin levels Most common cause: altered immunity with inflammation Interprofessional Collaborative Care (Nephrotic Syndrome) Main feature: increased protein elimination with severe proteinuria Treatments:ACE inhibitors (ACEIs): decrease protein loss Heparin: reduce vascular defects and improve kidney function Dietary changes: protein may need to be limited Mild diuretics: control edema and fluid retention Sodium restriction: control edema and fluid retention Hydration status: vascular dehydration common Nephrosclerosis Definition: degenerative disorder from changes in kidney blood vessels Pathophysiology: nephron blood vessels thicken; narrowed lumens; decreased kidney blood flow Associations: hypertension, atherosclerosis, diabetes mellitus Prognosis: may be reversible or progress to ESRD Genetic link: APOL1 allele Interprofessional Care (Nephrosclerosis) Hypertension control: ACE inhibitors and diuretics Goal: reduce albuminuria Polycystic Kidney Disease (PKD) Genetics: fluid-filled cysts develop in nephrons Common clinical features: hypertension, abdominal fullness and pain, cyst bleeding, hematuria, kidney stone formation, infections, systemic disease Etiology and Genetic Risk (PKD) Inheritance:Autosomal-dominant trait or autosomal-recessive trait Autosomal-dominant PKD is the most common inherited kidney disease Recognize Cues: Assessment (PKD) History: family history; pain; constipation; urine changes; hypertension; headaches Physical: distended abdomen; flank pain; cyst rupture may cause bright red/cola-colored urine Psychosocial: uncertainty, loss, fear Recognize Cues: Assessment (Cont.) Diagnostic assessment:Ultrasonography: primary diagnostic method MRI or CT: tissue oxygenation and inflammation data Urinalysis: may show proteinuria, hematuria, bacteria Take Actions: Interventions (PKD) Blood pressure management: ACEIs Pain management: acetaminophen; opioids Sodium restriction: less than 2 g/day Slowing CKD progression: tolvatpan? (tolvaptan); protein restriction Renovascular Disease Pathophysiology: processes affecting renal arteries narrow lumen; greatly reduce renal blood flow Epidemiology: often in people over 50 with sudden onset HTN Common causes: atherosclerosis or vascular hyperplasia Other causes: thrombosis; renal vessel aneurysms Recognize Cues: Assessment (Renovascular Disease) Key features: significant, difficult-to-control hypertension; poorly controlled diabetes or sustained hyperglycemia; elevated serum creatinine; decreased GFR Diagnosis: MRA; renal ultrasound; radionuclide imaging; renal arteriography Take Action (Renovascular Disease) Interventions: tailored to defect type; extent of narrowing; condition of surrounding vessels Drug therapy: multiple antihypertensives as needed Endovascular techniques: stenting Renal artery bypass surgery Diabetic Nephropathy Definition: vascular complication of diabetes mellitus Significance: leading cause of chronic kidney disease worldwide Severity: related to degree of hyperglycemia Management: the same as for CKD Renal Cell Carcinoma Nature: adenocarcinoma of the kidney; most common kidney cancer Paraneoplastic syndromes: anemia; erythrocytosis; hypercalcemia; liver dysfunction; hormone changes; hypertension Metastasis pattern: adrenal gland, liver, lungs, long bones, or other kidney Recognize Cues: Assessment (Renal Cell Carcinoma) History: age; genetic factors; exposure to heavy metals; weight loss; urinary changes; abdominal pain; fever Signs: flank pain; visible blood in urine (late sign); kidney mass Skin: pallor/ashen gray appearance; darkening of nipples; gynecomastia in men Diagnostics: urinalysis; hematologic studies; serum creatinine; BUN; CT; MRI; ultrasound; kidney biopsy Take Action: Interventions (Renal Cell Carcinoma) Goals: prevent metastasis; manage complications Nonsurgical: cryoablation; immunotherapies Surgical: nephrectomy (main option) Postoperative monitoring: assess for hemorrhage and adrenal insufficiency (hypotension; decreased urine output; altered consciousness) Kidney Trauma Etiology: penetrating wounds, blunt injuries, urologic procedures Classification: five grades depending on severity Recognize Cues: Assessment (Kidney Trauma) History: mechanism of injury Assess: pain, urine output, circulation Diagnostics: urinalysis; H&H; ultrasound; CT; KUB Take Actions: Interventions (Kidney Trauma) Nonsurgical management Drug therapy: bleeding prevention or control Fluid therapy: restore circulating blood volume Interventional radiology: drain collections or embolize area Surgical management: angiographic embolization; laparotomy; nephrectomy Care Coordination and Transition Management (Kidney Trauma) Teach how to assess for infection and complications; contact health care provider if symptoms arise Acute Kidney Injury (AKI) Pathophysiology: rapid reduction in kidney function leading to failure to maintain waste elimination, fluid/electrolyte balance, and acid–base balance Onset: occurs over a few hours to days; typically in the acute care setting Definition (current):Increase in serum creatinine by OR increase in serum creatinine to OR urine output < Etiology (AKI) Reduced perfusion to kidneys; damage to kidney tissue; obstruction of urine outflow Risk factors: shock; cardiac surgery; hypotension; prolonged mechanical ventilation; sepsis Higher risk: older adults or adults with chronic diseases Causes of AKI (Source categorization) PRE-RENAL: Impaired perfusion (Cardiac failure; Sepsis; Blood loss; Dehydration) RENAL: Glomerulonephritis; Small-vessel vasculitis; Acute tubular necrosis; Drugs; Toxins; Interstitial nephritis POST-RENAL: Urinary calculi; Retroperitoneal fibrosis; Benign prostatic enlargement; Prostate cancer; Cervical cancer; Urethral stricture/valves; Meatal stenosis/phimosis Promote hydration: drink 2–3 L of water daily for healthy adults Avoid exposure to nephrotoxic drugs Recognize Cues: Assessment (AKI) History: changes in urine appearance, frequency, volume; recent surgery, trauma, transfusions, allergic reactions; drug history (antibiotics, NSAIDs, contrast); coexisting conditions (DM, sepsis, PVD, liver disorder) Immunity-mediated AKI: influenza, colds, gastroenteritis, sore throats Anticipate AKI after hypotension or shock History of urinary obstructive problems Recognize Cues: Assessment (Cont.) Physical: hourly urine output; signs of azotemia and oliguria; fluid overload signs (pulmonary crackles, edema, confusion, dyspnea); vital signs for hypoperfusion/hypoxemia Laboratory assessment (AKI) Creatinine, BUN: elevated Blood electrolytes: abnormal Urine tests: abnormal specific gravity; sediment Imaging: US, CT, pelvis/kidneys KUB; MAG3 nuclear scan Kidney biopsy: uncertain diagnosis or immune response possible Take Action (AKI) Avoid hypotension; maintain normal fluid balance Reduce exposure to nephrotoxic agents and drugs Frequent laboratory monitoring; monitor I/O Drug therapy: diuretics; fluid challenges Nutrition: dietician consultation for protein and calorie needs; supplements; parenteral routes as needed Kidney Replacement Therapy (KRT) Definition: supportive strategy to purify blood, substituting for kidney function Indications: symptomatic uremia; persistent or rapidly rising hyperkalemia; severe metabolic acidosis; fluid overload impairing tissue perfusion Modalities: Intermittent and continuous hemodialysis (HD); peritoneal dialysis (PD) Access: temporary central venous catheter needed for initial access Chronic Kidney Disease (CKD) Pathophysiology: progressive, irreversible disorder lasting > 3 months; can progress to end-stage kidney disease (ESKD) Terminology: Azotemia = buildup of nitrogen-based wastes in blood; Uremia = azotemia with symptoms (muscle cramps, vomiting, edema, paresthesias) Stages of CKD Five stages by GFR category:Stage 1: GFR > 90 Stage 2: GFR 89–60 Stage 3: GFR 59–30 Stage 4: GFR 29–15 Stage 5: GFR < 15 Body System Changes in CKD Kidney: abnormal urine production; extracellular volume overload Metabolic: disrupted fluid/electrolyte and acid–base balance Cardiac: hypertension; hyperlipidemia; heart failure; pericarditis Hematologic and immunity: anemia; infection risk GI: halitosis; stomatitis; peptic ulcers Cognitive and functional: mental status changes; risk of drug toxicity Etiology and Genetic Risk (CKD) >100 different disease processes can cause progressive kidney function loss Two main causes leading to dialysis or transplantation: Hypertension and Diabetes mellitus Incidence and Prevalence (CKD) About 15% of adults in the U.S. have CKD Most with CKD do not know they have it Control diseases that lead to CKD Dietary adjustments: sodium, protein, cholesterol restriction Weight management: BMI 22–25 kg/m^2 Smoking cessation; exercise 30–60 minutes most days; limit alcohol Recognize Cues: Assessment (CKD) History: weight changes; medical history of kidney/urologic origin; drug use; dietary habits; GI/GU problems; energy changes; family history Physical: neurologic changes (lethargy, seizures, neuropathy, fatigue); CV signs (fluid overload, HTN, heart failure, pericarditis, potassium dysrhythmias); respiratory symptoms (dyspnea); hematologic signs (anemia, abnormal bleeding); skeletal signs (osteodystrophy, calcium absorption issues); urine changes (oliguria, color changes, proteinuria, hematuria); skin signs (jaundice, pruritus, uremic frost, bruises) Recognize Cues: Assessment (Cont.) Psychosocial: anxiety, fear; coping mechanisms; may need mental health support Laboratory & Imaging (CKD) Lab: Creatinine, BUN; electrolytes (Na, K, Ca, P, bicarbonate); Hemoglobin/hematocrit; GFR; Urinalysis Imaging: X-ray findings (not always abnormal); Kidney or CT scans Analyze Cues & Prioritize Hypotheses (CKD) Priority collaborative problems: Fluid overload; Decreased cardiac function; Weight loss; Potential for injury; Potential for psychosocial compromise Generate Solutions and Take Actions (CKD) Managing fluid volume: diuretics; fluid restriction; daily weights Improving cardiac function: ACEIs, calcium channel blockers (CCBs); BP monitoring Nutrition: dietician referral; protein/sodium/potassium/phosphate restriction; vitamin/mineral supplementation Preventing injury: transfer techniques; drug toxicity/levels; bone monitoring; infection risks; bleeding precautions Minimizing psychosocial compromise: sleep improvement; disease education; manage depression/anxiety Hemodialysis Purpose: remove excess fluids and waste; restore fluid/electrolyte and acid–base balance Mechanism: pass patient’s blood through an artificial semipermeable membrane Indication: stage 4–5 CKD with life-threatening manifestations or persistent discomfort Hemodialysis Patient Selection Criteria: symptoms due to disturbances of fluid/electrolyte and waste/toxin accumulation Common trigger: uremic symptoms (nausea, vomiting, confusion, seizures) or severe bleeding Other criteria: irreversible kidney failure when other therapies are unacceptable/ineffective; no disorders complicating HD; patient values and ability to maintain roles at home/work/school Hemodialysis Setting and Procedure Setting: hospital-based if recently started or complicated; otherwise community/freestanding center Process: blood and dialysate flow in opposite directions across a semipermeable membrane; diffusion removes wastes and reestablishes balance; duration is preset Hemodialysis System Components: dialyzer, dialysate, vascular access, HD machine Safety: built-in monitoring of vital signs, flows, pressures, delivered dialysis dose, plasma volume, and temperature Hemodialysis Anticoagulation and Vascular Access Anticoagulation: heparin delivered into the circuit; remains active 4–6 hours after dialysis Vascular access: internal AV fistula or AV graft for long-term HD AV fistula: surgically connect an artery to a vein; maturation ~2–3 months or longer AV graft: synthetic material; used if fistula does not develop or complications prevent use AV Fistula vs AV Graft (Diagrammatic description) Fistula: native connection between artery and vein (e.g., radial artery to cubital vein) Graft: synthetic conduit (e.g., loop/cubital/branchial configurations) Caring for the Patient with an AV Fistula or AV Graft Do not take blood pressure readings on access limb Do not perform venipunctures or IVs in access limb Palpate for thrills and auscultate bruits every 4 hours while awake Assess distal pulses and limb circulation Elevate affected limb after surgery; encourage ROM exercises Monitor for bleeding at needle sites and infection signs Do not carry heavy objects or place pressure on the access arm; avoid sleeping with weight on it Vascular Access Complications Thrombosis: most frequent complication; can be reopened with thrombolytic drugs Infections from cannulation Aneurysms: from repeated needle punctures Ischemia/steal syndrome: reduced arterial flow to tissues distal to fistula High-output heart failure risk due to shunted blood Temporary Vascular Access Special catheters for immediate HD Sites: subclavian, internal jugular, or femoral vein Size: much smaller; 4–8 hours session duration Subcutaneous devices may provide temporary access; mechanism opens with needle insertion and closes after removal Hemodialysis Nursing Care Determine which drugs to hold until after HD Monitor for post-dialysis side effects (hypotension, headache, N/V) Record vital signs and post-dialysis weight Avoid invasive procedures for 4–6 hours after dialysis due to anticoagulation Hemodialysis Complications Hypotension; dialysis disequilibrium syndrome Cardiac events in patients with cardiovascular disease Reactions to dialyzers (dialyzer reactions) during first-time filter use Peritoneal Dialysis (PD) Mechanism: exchanges in the peritoneal cavity; slower than HD; less common today (<10% of dialysis population) Peritoneal Dialysis: Patient Selection and Procedure Selection: good for those who cannot tolerate anticoagulation or have vascular access problems; provides flexibility Procedure: Silastic catheter placed in the abdomen Process: fill 1–2 L dialysate by gravity over 10–20 minutes; dwell time prescribed; drain by gravity into drainage bag Peritoneal Dialysis: Process and Additives Diffusion and osmosis across peritoneal membrane Dialysate may include heparin to prevent catheter/ tubing clotting Dialysate may contain potassium and antibiotics as needed Peritoneal Dialysis Complications Peritonitis: major complication; often due to connection site contamination Pain during inflow initially Exit-site and tunnel infections Poor dialysate flow often related to constipation Fibrin clot formation after catheter placement or with peritonitis Other: bleeding, bowel perforation Nursing Care for Peritoneal Dialysis Baseline vital signs; monitor weight (pre/post drain) to assess dry weight Monitor catheter exit-site dressings for wetness during procedure Monitor blood glucose in patients absorbing glucose from PD Maintain accurate inflow and outflow records for fluid balance Kidney Transplantation Candidate selection criteria: advanced kidney disease; reasonable life expectancy; medically and surgically fit Waiting list: in the U.S. generally when GFR < 20 mL/min Donors: living donors (best graft survival); non-heart-beating donors; cadaveric donors Kidney Transplantation Procedure Preoperative care: immunologic studies; dialysis 24 hours before surgery; blood transfusion before surgery Operative procedures: donor status-dependent; failed kidneys may be left in place unless infected or enlarged/painful New kidney is placed in the right or left anterior iliac fossa Kidney Transplantation Procedure (Cont.) Postoperative care: urologic management with catheter for decompression; hourly urine output for 48 hours; continuous bladder irrigation if prescribed; monitor input/output; urine may be pink-tinged initially Complications: rejection (most serious); thrombosis; renal artery stenosis (may require balloon angioplasty); wound problems/strictures Types of Kidney Transplant Rejection Acute rejection: 1 week to any time after surgery; oliguria or anuria; increased BP; enlarged, tender kidney Chronic rejection: months to years; gradual rise in BUN/serum creatinine; electrolytes changes; fatigue Hyperacute rejection: within 48 hours; fever and hypertension; pain at transplant site Care Coordination and Transition Management (Transplant) Home care: dietary needs; vascular access needs; equipment Self-management education: drug therapy; potential complications Resources: support groups; community support Evaluate Outcomes (Overall CKD/Transplant Context) Maintain appropriate fluid and electrolyte balance Maintain adequate nutritional status Avoid infection at vascular access site Use effective coping strategies Prevent or slow systemic complications of CKD (osteodystrophy) Assess for absence of anxiety or depression Health Promotion / Disease Prevention (AKI and CKD contexts) Maintain hydration; limit nephrotoxic exposure Manage chronic diseases (HTN, diabetes) to prevent CKD progression AKI diagnostic thresholds: ext{Increase in serum creatinine} OR ext{Cr}_{ ext{baseline}} imes 1.5 or more Urine output: V_{ ext{urine}} < 0.5~ rac{\text{mL}}{\text{kg}\cdot \text{hour}} ext{ for } 6~\text{hours} CKD stages (GFR, mL/min):Stage 1: GFR > 90 Stage 2: GFR 89–60 Stage 3: GFR 59–30 Stage 4: GFR 29–15 Stage 5: GFR < 15 Sodium restriction (CKD): less than 2 g/day PD fill volumes: usually 1–2 L of dialysate per exchange Dialysate anticoagulation duration: heparin remains active 4–6 hours after dialysis Immunosuppression-related considerations (transplant): clinical vigilance for rejection, thrombosis, stenosis Knowt Play Call Kai