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239 Cards in this Set
- Front
- Back
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functions of the kidneys
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EXCRETORY
-urine formation -excretion of waste -regulation of electrolytes -regulation of acid base -fluid/water balance -plasma osmolality NON-EXRETORY -RBC (erythropoietin) -metabolisis vit D to ACTIVE form -B/P (RENIN) -secretion of prostoglandins -degrades insulin |
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where are the kidneys in relation to the spinal cord
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from 12th thoracic to 3rd lumbar (adult)
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which kidney is higher and why
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the left is higher d/t the liver
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so what protects them
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ribs, muscle, FAT
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do the kidneys work with the adrenal glands
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no they have separate function and nerve/blood supply
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2 parts of the renal parenchyma
what does each part contain |
1) cortex
the thinner outer wall that contains NEPHRONS 2) medulla inner portion w/loops of Henle, vasa recta, and collecting ducts of juxtamedullary nephrons |
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renal pyramids
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ducts empty into these which then empty into renal pelvis
-each has 8-18 each |
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hilum
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concave part of kidney where artery enters and ureters and renal vein exit
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where does the renal artery stem from
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the abdominal aorta
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how much cardiac output goes to kidneys
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20-25%
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glomerulus
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-capillary bed used for glomerular filtration
comes from the afferent braches of renal artery then leaves from efferent arterioles back to renal vein then the inferior vena cava |
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nephron
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FUNCTIONAL UNIT OF KIDNEY
each has about a million F=initial formation of urine |
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how many nephrons can be lost before TX
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20% or more loss of functioning nephrons
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2 types of nephrons
which is more effective |
1) cortical (80-85%)
found in cortex 2)juxtamedullary LONG loops of Henle dip into medulla *the longer the tube=better ability to concentrate urine |
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2 basic components of a nephron
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1) filtering network of capillaries (GLOMERULUS)
2)tubule |
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filtering layers of glomerulus
what is needed for it to function |
1)capillary endothelium
2) basement membrane 3) epithelium allows fluid/small particles to pass but needs PRESSURE and BLOOD |
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what about the tubular component of nephron
parts and function |
starts with Bowman's capsule that surrounds glomerulus
also proximal, descending, ascending limbs of loop of Henle and cortical and medullary collecting ducts THIS PART SELECTIVELY FILTERS BASED ON BODY'S NEEDS |
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juxtaglomerular apparatus
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-site of RENIN production
-the distal tubule cells (macula densa) function with afferent arteriole that are next to them |
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urothelium
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transitional cell epithelium that lines bladder and ureters that prevents resorption AKA TEFLON
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what moves urine from the pelvis into bladder
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gravity helps but also peristalsis
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ureteropelvic junction
ureteral segment ureterovesical junction |
3 narrow areas of the ureter where obstruction is most common
-obstruction at ureteropelvic junction is the worst because it is so close to the kidney that urine is more likely to get backed up |
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bladder capacity -normal
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400-500mL
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antegrade flow of urine
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downward flow AKA efflux
opposite is retrograde or reflux ureterovesical junction helps prevent this due to the angle it enters the bladder |
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layers of the bladder wall from outside in
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-adventitia (CT)
-detrusor (smooth muscle) -mucosal lining of loose CT -transitional cell epithelium(urothelium) |
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what about renal sphincters
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like those in lower GI there are 2
1) inner-involuntary 2) outer -voluntary |
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micturation
what level of spine allows for sphincter relaxation |
AKA voiding
increased pressure closes ureterovesical junction and keeps urine in ureters S1 and S2 allow for relaxation |
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3 step process of nephron urine formation
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1) glomerular filtartion
2) tubular reabsorption 3) tubular secretion |
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basic substances filtered by kidneys
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-Na, chloride, Bicarb, K, glucose, urea, creatinine, and uric acid
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renal glycosuria
common in ? |
recurrent or persistent glucose in urine because there is more than GFR can handle
diabetes and pregnancy |
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glomerular filtration (step1)
how much of the blood is filtered and was is this fluid called |
20% of blood that passes into kidney is filtered the fluid is known as filtrate or unfiltrate
this is NOT selective ALL particles that are small enough and water are filtered |
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tubular reabsorption (step 2)
how much is reabsorbed where does most of this take place |
substance moves from filtrate back to peritubular capillaries or vasa recta into tubular filtrate
most occurs in proximal tubule this happens to 99% of the filtrate |
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tubular reabsorption
tubular secretion how does it happen |
passive and active transport
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where does filtrate become concentrated into URINE
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in the distal tubule and collecting ducts which are influenced by HORMONES
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what indicates kidney's inability to concentrate urine and is a common early sign of kidney disease
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concentration as measured by OSMOLALITY and specific gravity
dilute urine with a fixed specific gravity (1.010) or fixed osmolality (300) |
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average fluid intake and loss a day
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1300 from oral liquid and 1000 from food
-900mL lost from skin/lungs -50mL from sweat -200mL from feces |
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how many electrolytes are lost in urine a day
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should equal what is consumed so think about that when evaluating
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kidney's role in acid base balance
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keep bicarb and excrete acid
-bicarb is sm=is lost/reabsorbed easily -renal tubular cells also make it -acid excreted in free form until urine pH is about 4.5 -the rest must be bound to chemical buffers like phosphate ions and amonia -bound acids do not effect urine pH |
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what acids can ONLY be rid of via the kidneys
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-phosphoric and sulfuric acids
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what monitors the B/P of kidneys
what happens when it is LOW too HIGH |
vessels called the vasa recta
specialized juxtaglomerular cells called DENTA CELLS secrete RENIN RENIN secretion stops |
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what is the most powereful known vasoconstrictor
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angiotensin II
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one of the most common causes of HTN (renal)
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failure of renin-angiotensisn-aldosterone system to function
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renal clearance
formula |
-ability of kidneys to clear solutes from plasma
-24 hour urine is primary test -measures esp for creatinine -creatinine good measure for GFR -start time after void -keep sample cool/on ice -measure serum creatinine 1/2 way volume of urine X urine creatinine --------------------------------------- serum creatinine |
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so what happens to creatinine when kidney function decreases
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serum creatinine goes up but down in urine
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normal GFR
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125mL/min to 200mL/min
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when is erythropoietin released
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when kidneys detect decrease in O2 tension in renal blood flow
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prostoglandin E and prostacyclin
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made by kidneys and have vasodilatory effect to help maintain renal blood flow
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urea
how is it excreted |
-major waste product of protein metabolism
-protein to amonia to urea -ALL is excreted in urine |
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uric acid
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waste product of purine metabolism -excreted in kidneys
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how do we know when we have to pee
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sympathetic nerve pathways at level of T10 to T12
where peripheral hypogastric nerve innervation allows it to keep on filling up this filling stretches the detrusor muscle that sends message to cerebral cortex via parasympathetic pelvic nerves at level of S1 to S4 |
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bladder pressure and why it's important
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must remain lower than 40cm H2O
-if higher then urine cannot leave pelvis -bladder stretching allows for this |
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how full is bladder when you get the need to pee
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150-200mL is slight urge
300-500mL is discomfort and strong 2000mL means you have lost the sense |
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how often do you go
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q2-4 hours depending on average
less at night d/t vasopressin more in old d/t less vasopressin and stretch |
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normal residual volume
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50mL or up to 100mL in old
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renal changes in old people
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-GFR decreases 1mL/min per year after age 35-40
-sclerotic changes -decreased estrogen/vasopressin -BPH |
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anuria
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decreased urine production
less than 50mL a day |
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oliguria
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less than 500mL a day
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frequency (urinary)
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more than every 3 hrs
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enuresis
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bed wetting
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remember renal issue s/s can mimic
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GI issues d/t shared autonomic and sensory innervation and renointestinal reflexes
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major s/s of renal issues
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-pain
-GI symptoms -changes in voiding -unexplained anemia |
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anemia of chronic disease s/s
what lab test do they use |
-fatigue
-exercise intolerance -SOB used to test Hct now Hgb is better |
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costovertebral angle
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lower border of 12th (last) rib and spine from back view
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bruits at left and right of mideline in upper quadrants
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bruits (low pitched murmurs)
may indicate renal stenosis or aneurysm |
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percussion of bladder
palpation |
start at midline above umbilicus and go down
will change from tympanic to dull dullness after void=retention only if moderately distended |
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prostate cancer /BPH testing
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PSA (prostate specific antigen ) tested for 1st then digital if + result
digital exam 1st may cause false + PSA |
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urethrocele
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anterior vaginal wall into urethra
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cystocele
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herniation of bladder into vaginal vault
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pelvic prolapse
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cervix bulging into vaginal vault
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enterocele
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herniation of bowel into posterior vaginal wall
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rectocele
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herniation of rectum into vaginal wall
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Marshall-Boney maneuver
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index and middle fingers in vagina to support either side of urethra as woman asked to repeat valsalva maneuver and cough
IF urine is spilled without insertion of fingers to assess muscular and ligament strength =refer if leak after test |
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how to assess for supraspinal causes of urinary incontinence
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DTR of knee
sacral nerve for lower extremities is same peripheral nerve for urinary incontinence also gait and heel-toe walking |
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what does urine dipstick test for
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protein and glucose
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hematuria
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more than 3 RBC per microscopic field (high power)
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urine dipstick test for proteinuria
what can alter results |
-screening test only
-cannot detect less than 30mg/dL -concentration, blood, dye can effect results -fever, strenous exercise, and prolonged standing can cause benign and transient proteinuria |
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microalbuminuria
what is it an early sign of (maybe) |
20-200mg/dL of protein in urine
-early sign of diabetic neuropathy |
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when will renal function tests start to show abnormal values
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when GFR is 50% or less of normal
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red or pink urine
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blood
beets/blackberries (phenytoin) Dilatin senna |
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nursing stuff for MRI pt prep
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-NO METAL or credit cards
-this includes transdermal med patches -stethoscopes, implants, etc -no IRON supplements -may be claustrophobic -no alcohol, caffiene, nicotine 2 hr B4 -no food 1 hr before |
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nursing stuff for nuclear scans
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-encourage fluids after to flush out agents
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nursing stuff kidney biopsy
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-fast 6-8 hrs before test
-get urine specimen b4 to compare -breath in and hold during insertion -prone w/sandbag under abdomen if sedated |
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blue or blue green urine
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-dyes
-methylene blue -pseudomonas organisms -drugs(amitriptyline/triamterine) |
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yellow to milky white urine
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-infection
-vaginal cream |
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colorless to pale yellow urine
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-dilute d/t diuretics, alcohol, diabetes insipidus, glycosuria, renal dz, or XS fluid intake
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bright yellow urine
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vitamins
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orange to amber urine
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-concentrated d/t dehydration/fever
-bile -bilirubin -carotene (carrots/etc) -drugs(pyridium/ nitrofurantoin) |
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brown to black urine
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-old blood
-urobilinogen/ bilirubin -melanin -porphyrin -VERY concentrated -drugs (Flagyl/ iron, senna, quinine, methyldopa) |
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renal pelvis holds how much
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3-5 mL
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how much in normal foley cath balloon
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10cc
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TURP
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trans urethral resection prostate
-knock em out and drill thru it -may see 3-way foley cath after sx -uses a drip to flush catheter -balloon has 30cc -uses TENSION to stop bleeding |
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how often to perform cath care
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2x a day
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CKD
primary cause(s) |
Chronic Kidney Disease
-damage or decrease in GFR for 3 OR MORE MONTHS -if untreated can progress to end stage -#1 Diabetes #2 HTN /#3 Glomerular destruction -thought to be d/t inflammation that is not organ specific |
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5 stages of CKD
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-based on GFR
1) >90 -normal or decreased GFR =decreased renal reserve 2) 60-89-mild decrease 3) 30-59- moderate=renal insufficiency 4)15-29-severe 5) >15 or 10% of GFR= kidney failure AKA ESRD end stage renal disease 5) death/ transplant/ dialysis |
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renal insufficiency
lab value changes |
STAGE 3
-BUN and creatinine are starting to rise may see polyuria d/t decreased concentration |
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nephrosclerosis
2 types s/s TX |
hardening of the renal arteries
-often d/t diabetes/HTN -common cause of CKD/ESRD 1) malignant-FAST -often with HTN w/DBP over 130 -results in decreased blood to kidney -more common in young men -progresses fast death by uremia 2) benign -SLOW (20-30 yrs) -more in older men d/t atherosclerosis/HTN early s/s-casts, protenuria late-renal insufficiency TX: tx of HTN/ ACE inhibitors |
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Primary Glomerular Disease
TYPES |
-disease that destroy glomerulus
-antigen antibody complexes trapped in glomerular capillaries -IgG found also in capillary walls -results in inflammation THINK acute nephritic syndrome and GLOMERULONEPHRITIS TYPES: -infectious -rapidly progressive -membranous |
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acute nephritic syndrome
AKA Glomerulonephritis |
-clinical manifestation of glomerular inflammation
-inflammation of glomerular capillaries that can be acute or chronic |
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major s/s of glomerular injury
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-proteinuria
-hematuria -decreased GFR -decreased Na excretion -edema and HTN |
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postinfectious causes of
acute nephritic syndrome AKA Glomerulonephritis |
-GROUP B HEMOLYTIC STREP (throat) 2-3 WEEKS BEFORE
-impetigo -acute viral(mumps, varicella zoster, upper resp tract, HIV, hep B, Epstein-Barr -meds -autoimmune dz |
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azotemia
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abnormal concentration of NITROGENOUS wastes in the blood
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ACUTE nephritic syndrome
AKA Glomerulonephritis s/s DX TX Nursing |
-hematuria
-edema/HTN/cardiomegaly/JVD -pulmonary edema -azotemia -proteinuria/pitting edema -COLA COLORED urine d/t RBC/protein -hypoalbuminemia -BUN and creatinine goes up as output decreases -seizures and confusion in old -LARGE/EDEMA/KIDNEYS d/t congestion DX by kidney biopsy -HTN encephalopathy (med ER) -CHF/pulmonary edema -ESRD in wks-months if no tx TX-corticosteriods/ HTN meds -assess for infections (past/hx) -low protein/Na and high carbs -daily wt with I+O -fluid restriction based on wt -verbal/written instruction of s/s to notify MD |
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drug of choice for streph infections
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penicillin
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CHRONIC Glomerulonephritis
s/s Nursing |
-slow d/t repeated or untreated injury
-kidneys reduced in size w/rough irregular edges -can progress to stage 5/ESRD -1st may be a nose bleed d/t HTN -loss of wt/strength -nocturia -headache,dizziness,irritability -GI disturbances THEN S/S of CKD/RENAL FAILURE -looks poorly nourished -yellow-gray skin -periorbital and dependent edema -retinal damage/papilledema d/t HTN -cardiomegaly/gallop/JVD/CHF -peripheral neuropathy -decreased DTR -pericarditis w/friction rub -pulsus paradoxus -FIXED SPECIFIC GRAVITY 1.010 -urinary casts -s/s of GFR BELOW 50/mL -same as those with acute -protein must be HIGH BIOLOGIC VALUE -prompt tx of UTI's -Dialysis PRN |
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s/s of GFR below 50mL/min
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This is Stage 3 AKA renal insufficiency
-hyperkalemia -metabolic acidosis -anemia -hypoalbuminemia/edema -hyperphosphatemia -hypocalcemia -mental status change -impaired nerve conduction d/t electrolytes and uremia |
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pulsus paradoxus
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difference in B/P during inspiration and expiration of more than 10mmHg
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Patho of acute nephritic syndrome
Glomerulurnephritis (spelled so wrong) |
Antigen (group B hemolytic strep)
- antigen-antibody product - complex in glomerulus - increased epithelial cells lining glomerulus - leukocyte infiltration - thickening of filtration membrane - scarring and loss of membrane - decreased GFR |
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PATHO of nephrotic syndrome
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damaged glomerular capillary membrane
- loss of plasma protein (albumin) - 1)stimulates synthesis of lipoproteins - hyperlipidemia 2) hypoalbuminemia - decreased oncotic pressure - generalized edema - activation of Renin-Angiotensin sys - sodium retention - edema |
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nephrotic syndrome
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type of renal failure where there is increased glomerular permeability which results in MASSIVE PROTENURIA
-caused by glomerular DAMAGE |
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nephrotic syndrome
s/s nursing |
-proteinuria (esp ALBUMIN) more than 3.5g/day =HALLMARK DX
-hypoalbunemia -diffuse edema/soft and pitting -high serum cholesterol -hyperlipidemia -ascites -FROTHY URINE (d/t fats/protein) complications include emboli and increased atherosclerosis d/t high lipid levels TX: diuretics, ACE inhibitors, lipid lowering meds nursing at first is like acute glomerulonephritis then like that of ESRD as it gets worse |
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PKD
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Polycystic Kidney Disease
-5th leading cause of kidney failure -genetic disorder -growth of many cysts in kidney -cysts filled w/fluid that destroy nephron -can become large and overtake space -can also form in other organs heart/brain/liver/etc -"simple" cysts are harmless NOT the same as PKD -UTIs/HTN/ANUERYSM/DIVERTICULUM -90% autosomal dominant seen later in life -10% recessive seen b4 or soon after birth |
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Renal Cancer
classic s/s TX nursing |
-most common renal carcinoma comes from epithelium
-metastasis is fast/early -to lungs/bone/liver/brain/other kidney -most often found on PALPATION -other s/s of metastasis -radical nephrectomy -partial nephrectomy -renal artery embolization -chemo and radiation -currently no medications to tx -PAINLESS hematuria and flank pain -must have annual exam and chest X-ray to screen for recurrence after tx |
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radical nephrectomy
VS partial nephrectomy |
remove kidney, adrenal gland, surrounding fat and Gerota's fascia, and lymph nodes
AKA nephron sparing sx -used if tumors in both or in only functional kidney -only parts of kidney are removed |
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renal artery embolization
classic symptom complex after procedure |
-embolizing material
(Gelfoam, autologous blood clot, coil) -injected into artery to occlude tumor vessels -makes it easier to remove kidney, stimulates immune response, and prevents tumor cells from traveling in artery postinfarction syndrome= -lasts 2 to 3 days after -abdomen and flank pain -fever and GI symptoms -fluid and oral restriction to tx GI |
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Bladder Cancer
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-smoking/work/coffee/parasitic bladder infections
-prostate,colon,rectal caner -gross PAINLESS hematuria, frequent UTI's -back/pelvic pain= metastasis TX=bladder removal in men causes IMPOTENCE |
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ARF
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Acute Renal Failure
-rapid loss (less than 4 weeks) of renal function d/t kidney damage -50% or MORE INCREASE IN CREATININE ABOVE BASELINE -increased BUN -increased K and decreased Na -reduced urine output -polyuria=kidneys are improving |
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ARF classified by......
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causes
1) pre-renaln(before the kidney) reduced blood flow to kidney 2) intrarenal-damage to parychema -acute tubular necrosis most common 3) post-renal (after kidney) obstruction of urine flow |
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4 phases/stages of AFR
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1) starts with what caused it
2)oliguria period -24-48hrs +after start -increased serum levels of waste=azotemia d/t urine output of less than 40mL/day -uremic symptoms and hyperkalemia {nonoliguric form pt will have normal urine output most often seen after nephrotoxic agents, burns, injury, halogenated anesthetics} 3)diuresis period -2 to 3 weeks later -increase in GFR and urine output -monitor for DEHYDRATION -no selective reabsorption -electrolyte loss BIG RISK esp K 4) recovery period -3 to 12 months -lab values return to normal -GFR permanently reduced 1-3% |
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one of the earliest signs of tubular damage
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inability to concentrate urine
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ARF prerenal s/s
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-increased BUN (out of PROPORTION to creatinine)
-increased creatinine -decreased urine output -<20 mEq/L urine Na -none to few hyaline casts -increased urine osmalality to 500 -increased urine specific gravity |
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ARF intrarenal s/s
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-increased BUN
-increased creatinine -often decreased urine output ->40 mEq/L urine Na -abnormal casts and debris -urine osmalality to 350/ like serum -low normal urine specific gravity |
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ARF postrenal s/s
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-increased BUN
-increased creatinine -decreased or no urine output -may be <20 mEq/L urine Na -often no sediment -urine osmalality increased or= serum -varied urine specific gravity |
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nephrotoxic medEications
precautions to take if using them |
aminoglycosides, gentamicin, tobramycin, colistimethate, polymyxin B, amphotericin B, vancomycin, amikacin, cyclosporine
BUN and serum creatinine should be obtained for BASELINE within 24 hours of start and then at LEAST 2x A WEEK while taking |
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radiocontrast induced nephropathy
what are some precautions to take to help prevent this from happening |
-major cause of hospital acquired ARF
-baseline creatinine more than 2mg/dL is HIGH RISK -N-acetylcysteine and Na bicarb before and during decrease risk -prehydration with NS is BEST |
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most life threatening electrolyte imbalance with pt's w/renal disorders
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Hyperkalemia
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Kayexalate
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-used to tx hyperkalemia
-trades Na ions for K ions -may be enema or PO -Sorbital wil increase laxative effect -colon major site of K exchange -leave enema 30-45 minutes -reverse osmosis if left too long -may follow w/cleansing enema |
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Nursing Management of Acute Renal Failure
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-pt will lose 1/2 to 1 lb a day if negative nitrogen balance
-if pt does not or rise in B/P suspect fluid retention -low protein high carbs until diuretic phase -after that high protein and calories -phosphorus and potassium restricted -IV meds given in smallest possible volume -daily wts and I+O's -monitor fluid status -monitor for s/s electrolyte imbalance -reduce metabolic rate (fever/activity) -STRICT ASEPSIS with invasive stuff -avoid urinary catheters when can -AVOID INFECTION -SKIN may be itchy and dry, short nails -encourage family to touch/talk to pt during dialysis -EDUCATE |
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primary cause of death in pt's with ESRD
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cardiovascular disease
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lab values with ESRD
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-GFR 10% or less / or >15
-decreased creatinine clearance -increased serum creatinine and BUN |
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ESRD manifestations
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-kidneys cannot concentrate or dilute urine
-so Na excess OR deficit are possible -Na AND FLUID IMBALANCE -METABOLIC ACIDOSIS -ANEMIA -HYPERPHOSPHATEMIA -HYPOCALCEMIA (made worse by loss of Vit D metabolism) -uremic bone dz AKA renal osteodystrophy -clacification of blood vessels -UREMIC FETOR -INFERTILITY -changes in LOC AND OTHERS SEEN WITH OTHER STAGES OF RENAL FAILURE |
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hyperposphatemia and hypocalcemia meds (ESRD/etc)
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BINDERS (Ca carbonate or acetate) must be GIVEN WITH FOOD and AVOID antacids if contain Mag
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anemia -lab value (Hct)
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hematocrit less than 30%
remember Hgb is better measure |
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Epogen
side effects time to take effect target levels for ESRD |
human erythropoietin (DRUG)
target Hct 33-38%/ Hgb 12g/dL given IV or SQ 3x a week (ESRD) may take 2-6 weeks to work risks=HTN, low iron, clotting, seizures -often given with iron |
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fluid allowance for ESRD
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500-600mL more than previous days output
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pt teaching for ESRD what to report
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S/S of:
-worsening renal failure (N/V, change in urine, uremic fetor) -hyperkalemia (muscle weakness, cramps, diarrhea) -access problems (clots, infection, etc) |
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urgent indication for dialysis in pt with renal failure
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pericardial friction rub
others include uremic symptoms fluid imbalance not corrected by other tx hyperkalemia |
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s/s uremia
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n/v, severe anorexia, lethargy
CHANGES IN LOC |
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hemodialysis
how often and how long is it |
short term or long term
3-4x a week at 3-4 hrs a pop |
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risks of hemodialysis
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STRESS on cardiac system =SHOCK
if fluid pulled to fast or too much n/v, sezuires, resp and cardiac arrest, cramps |
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how do we weigh pt for dialysis and why
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use KILOS it's more accurate
this determines how much fluid will be removed |
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what does dialysis even do
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to remove waste and fluid of course
especaily the nitrogenous TOXIC waste |
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dialyzer
2 compartments and how they run |
"artificial KIDNEY"
a synthetic semipermeable membrane 1)blood 2) dialysate run countercurrent to increase gradient |
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3 principles of hemodialysis
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1) diffusion-how wastes move
2) osmosis -how water moves 3) ultrafiltration=fluid moves from area under HIGH PRESSURE to that of LOW PRESSURE (more effective) |
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dialysate
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fluid made of electrolytes in perfect extracellular concentration this can be adjusted to meet pt's needs
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how is a new access site made if it must be used NOW (acute hemodialysis)
what are the risks |
PERMACATHS
double-lumen non cuffed LARGE -bore cath put into a major vein most often subclavian, internal jugular, or femoral vein *if a cuffed cath is used the site will heal around it -for longer use -high risk INFECTION and HEMORRAGE r/t direct access |
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preferred method of PERMANENT access for hemodialysis
how is it done why do they do that how long to mature what to teach pt to help process why is this the best option |
Arteriovenous Fistula (AVF)
surgical joining (anastomising) an artery to a vein either side by side or end to end to increase the size of the vein via arterial pressure so it can hold a BIG needle (14,15,16G) 2-3 months perform hand exercises lasts the longest |
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why do the hemodialysis access sites wear out
so is it common for this to happen and what do the do |
stenosis, infection, and thrombosis from repeated injury
YES, you will see pt's with multiple sites -ASK WHICH IS THE GOOD ONE and check for bruit and thrill |
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arteriovenous graft
why would they do it like this |
like an AVF but a GRAFT material is used to join the vessels
the vessels may not be good like in diabetics |
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most common reason chronic hemodialysis pt's are hospitalized
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their access site FAILS
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leading cause of death in pt's getting hemodialysis and why
what are some other common complications |
cardiovascular disease -STRESS and Ca deposits in vessels
anemia-d/t blood loss, ulcers, dz vomiting and hypotension-d/t rapid fluid loss s/s of electrolyte LOSS SLEEP DISORDERS-d/t tx regimen dialysis disequilibrium-d/t CEREBRAL FLUID SHIFTS |
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what causes the pruritis seen in renal pt's
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phosphorus accumulates in the skin
uric acid crystals could also cause |
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can a pt take medications before dialysis
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FAT SOLUBLE drugs and VITAMINS will not be lost
but WATER SOLUBLE ones will anthypertensives usually held d/t rebound hypotension if removed this is why dialysis is used in SOME drug OD's |
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what is the max amount of weight a pt should be gaining between dialysis tx
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less than 1.5kg
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how long (at a time) should you teach a pt newly diagnosed with a FATAL dz (like ESRD)
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10-15 minutes at a time but you should assess them individually as well
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metallic taste in mouth (renal pt)
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symptom of uremia and need for dialysis
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continuous renal replacement therapies (CRRTs)
why use this pros and cons |
uses a HEMOFILTER
for those that cannot handle hemodialysis less risk of shock, no dialysis machines, can be started ASAP BUT it is CONTINUOUS |
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Peritoneal Dialysis
who is this used for pros and cons biggest RISK |
uses peritoneal membrane as the semipermeable membrane (FILTER)
those that want the Independence and those that can't do hemo d/t heart/lung dz, DM, intolerance to heparin, elderly, etc independence, less dietary restriction, reduced risk of s/s CONS: takes 36-48 hrs to do what hemo does in 6-8, done more frequent, causes abdominal distention, must be able to perform at home PERITONITIS and plueral effusions |
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where is catheter placed in Peritoneal Dialysis
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often on pt's non dominant side
(broad spectrum antibiotics given during) |
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basic steps to Peritoneal Dialysis
how it is done |
-weight obtained
EXCHANGE 1) FILL-dialysate infused via gravity and tube is clamped 2)DWELL time (max 5hrs?) 3) drained by gravity -weighed again REPEAT |
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what color drainage will be seen with Peritoneal Dialysis
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may be a little bloody at first
may also see blood duing menses then should be CLEAR or straw if cloudy=THINK INFECTION |
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what controls how much water is removed during Peritoneal Dialysis
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the amount of DEXTROSE in the dialysate
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Peritonitis
1st sign in Peritoneal Dialysis other s/s dx and tx |
cloudy dialysate drainage
LATER: diffuse abdominal pain w/rebound tenderness hypotension malnutrition=d/t PROTEIN LOSS CULTURE and antibiotics some times given via intraperitoneal administration or ADDED TO DIALYSATE |
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effluent
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drainage
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long term complications of Peritoneal Dialysis
and WHY |
-hypertriglyceridemia d/t possible increase in atherogenisis (HTN meds, statins, blood thinners)
-hernias d/t increased abdominal pressure -low back pain and anorexia d/t fluid in abdomen -sweet taste in mouth d/t glucose in dialysate -mechanical problems/blockages d/t clots, constipation, etc |
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acute intermittent Peritoneal Dialysis
common routine what does RN do what must be recorded |
hourly exchange=10 minute infusion, 30 minute dwell, 20 minute drain
-warms and hangs bags -monitor V/S, labs, s/s fluid status -RECORD:use FLOW SHEET -pt status and measurements -fluids, amount,type, meds added -time to instill,dwell,drain -look of fluid |
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continuous ambulatory Peritoneal Dialysis
how often is it done describe this a little |
2nd most common form of dialysis for pt's w/ESRD
4-5x a day 24/7 pt must wash hands and wear a mask often uses a Y set must be sterile mask must be worn by anyone within 6 feet of area when a connection is made or d/c and hands must be washed |
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who cannot receive continuous ambulatory Peritoneal Dialysis
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those w/scar tissue d/t need for catheter placement
those that cannot do this AT HOME d/t arthritis, etc immunocompromised d/t meds or dz pt's w/diverticulitis d/t potential rupture pt's w/back pain d/t aggravation |
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continuous cyclic Peritoneal Dialysis
how is this done pros and cons |
uses a machine called a CYCLER
pt receives intermittent dwell time at night then a LONGER dwell time during day allows more freedom and reduces risk of infection d/t decreased handling of site |
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anephric
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pt without kidneys
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dietary restrictions for Peritoneal Dialysis
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-HIGH PROTEIN d/t protein loss of tx
-high FIBER to decrease cinstipation -NORMAL Na, K, and fluid -may need reduced carbs if wt gain |
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protecting vascular access for hemodialysis
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-NO B/P, sticks, tight clothing/jewelry
-assess bruit and thrill q8hrs |
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why would you NOT find a bruit and thrill in access site
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CLOTS are #1
caused by hypotension or reduced flow |
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s/s of....
pericarditis d/t uremic toxins may progress to..... which may progress to...... can be dx by , BUT |
substernal chest pain,fever, pericardial friction rub, pulsus paradox
EFFUSION=friction rub disappears, distant and muffled heart sounds, ECG shows low voltage, and pulsus paradoxus gets worse CARDIAC TAMPONADE= narrowing of pulse pressure, muffled or inaudible heart sounds, crushing angina, dyspnea, hypotension CHEST-X-ray but ASSESS for IT |
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best time to give blood transfusion to pt receiving dialysis and why
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DURING HEMODIALYSIS
the dialysis will remove the excess K |
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catheter care for CAPD
how and how often |
daily or 3-4x a week
liquid soap and water do NOT submerge in water |
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when are oral fluids allowed to be given to pt's after abdominal/renal sx
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after passage of flatus
bowel sounds?? |
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kidney transplant
types of donors/who is best who cannot donate or receive organ what happens to old kidney and where do they put new one,why sign of successful sx |
living or DEAD
1)identical twin 2)sibling 3)parent cancer, chronic infection, chronic heart/lung dz, autoimmune dz, hepatitis, current substance abuse, morbid obesity, HTN, DM old kidney stays in NEW one put in iliac fossa for better blood supply URINE PRODUCTION |
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acute and chronic kidney transplant rejection
when does it happen, how is it treated, what are the s/s |
acute:
days to 4 months after (most w/n 1st 2wks) may happen again later SAME S/S of KIDNEY FAILURE serum creatinine more than 20% rise often tx w/CYCLOSPORINE dialysis until it passes chronic: months to years later s/s HTN, proteinuria, renal failure IRREVERSIBLE |
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s/s of acute kidney transplant rejection in pt getting cyclosporine
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assymptomatic rise in serum creatinine
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how soon after kidney transplant will you see urine
live donor and dead |
live -may be ASAP
dead-may take 2-3 weeks |
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renal trauma 4 types of BLUNT
what should RN do |
can be blunt (most common) or penetrating
1)contusion 2)minor laceration (only cortex) 3)major laceration 4)vascular injury -assess for s/s SHOCK -collect ALL urine (hematuria s/s of injury) -outline mass wit pen if present to assess -suspect other organs have also been damaged |
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classification of UTIs
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1) upper (above bladder) OR lower
and 2) uncomplicated -community aquired, often nonreccurent complicated often nosocomial or d/t other condition often recurrent |
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cystectomy
side effect |
removal of bladder
impotence in men |
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bacteriuria
in women and men |
more than 10(5) colonies of bacteria per mL of urine in clean catch midstream, women
men 10(4) |
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pyelonephritis
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inflammation of renal pelvis
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pyuria
what does it mean |
WBC in urine
more than 4 per high powered field could be UTI or kidney stones, renal issues |
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urosepsis
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sepsis resulting from infected urine
-most often d/t UTI |
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glycosaminoglycan (GAG)
what meds effect it |
hydrophilic protein found in bladder, lines the walls creating a barrier of water between the urine to help prevent bacterial adhesion
saccharin, aspartame, tryptophan metabolites can degrade this barrier TEFLON COATING |
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urethrovesical reflux
causes |
backflow of urine from urethra into bladder
sneezing, coughing, etc |
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ureterovesical or vesicoureteral reflux
causes |
backflow of urine from bladder into ureter(s)
ureterovesical valve or other anomalies |
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most common types of bacteria for UTIs
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E.coli
Psuedomonas and Enterococcus more common in males and those with catheters |
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3 routes of infection for UTIs
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1) transurethral (ascending)
2) hematogenous 3) direct extension-from GI fistula |
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common s/s of UTIs
uncomplicated lower complicated |
burning, frequency, urgency, nocturia, incontenince, suprapubic or pelvic pain, hematuria, back pain
*FATIGUE and confusion in elderly may also see signs of shock |
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nursing interventions for UTIs
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-heat to perineum to reduce pain
-encourage fluids/ WATER is BEST -avoid coffee,tea,soda,alcohol,spice -frequent voiding q2-3 hrs -showers over baths -void after sex (females) -good hygiene -don't douche |
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acute pyelonephritis s/s
chronic |
-enlarged kidneys
-pain in costovertebral angle -fever, chills, leukocytosis, bacteriuria -painful urination d/t repeated or untreated attacks of acute -kidneys become scarred, contracted, and nonfunctioning -HTN, uremia, stones, etc -other s/s of renal insufficiency |
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stress incontinence
common med |
often d/t weakened muscles because of advanced age or multiple vaginal births
cough, sneeze, laugh, move sudafed=urinary retention |
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urge incontinence
common med |
uninhibited detrusor muscle
may be neurogenic dysfunction just can't hold it anticholinergic meds=inhibit contraction |
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functional incontinence
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pt may be confused or unable to attend to own need-no anatomical problem
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iatrogenic incontinence
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d/t extrinsic medical factors
like meds (alpha-adrenergics) |
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mixed incontinence
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just what it sounds like, there are a couple types at same time
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causes of transient incontinence
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DIAPPERS
Delerium Infection (UTI) Atrophic vaginitis, urethritis Pharmological agents Psychological factors Excessive urine production (DM.etc) Restricted activity Stool impaction |
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periurethral bulking
any restrictions? |
collagen injected within walls of urethra
pt d/c after 1st void lasts 12-24 months good option for elderly, etc |
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urinary retention
what can it cause common causes of it |
bladder does not fully empty
overflow incontinence/INFECTION stone formation, hydronephritis obstruction (BPH,stones,clots) Meds(anticholinergics, antidepressants/antihistamines/beta blockers/ anti psychs) Neurological disorders |
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caths to empty distended bladder
how much, how fast why |
500mL at a time clamp for 30min in between
to prevent SHOCK |
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neurogenic bladder
2 types |
LESION in nervous system
1) spastic or reflex lesion is above voiding reflex arch sensation to void is LOST= incontinence 2)flaccid lower motor neuron lesion commonly from trauma (spinal) bladder fills but can NOT VOID |
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suprapubic catheter
when can they take it out |
tube is clamped for 4 hours and them pt voids, if residual is less than 100mL morning and evening it is removed
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normal urine pH
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4.5-8
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urolithiasis
nephrolithiasis what are they made of |
stones in urinary tract
stones in the kidney Ca oxalate, Ca phosphate, uric acid |
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most common type of renal stones
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Calcium stones
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uric acid stones
common causes and what to avoid |
gout, myeloproliferative disorders
avoid PURINE: shellfish, anchovies, asparagus, mushrooms, fish, fowl, nuts, oats, peas, and organ meats protein may be limited |
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cystine stones
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seen only in pt with RARE inherited disorder that effects renal absorption of cystine (an amino acid)
TX: low protein diet, lots of fluids, alkalinized urine |
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oxalate stones tx
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dilute urine maintained
limit oxilate foods: spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran |
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pain seen with stones in renal pelvis
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intense deep ache in costovertebral region
may radiate down to bladder or testes hematuria and pyuria possible n/v/d may also be seen |
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pain seen with stones in ureter
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acute, VERY PAINFUL, wave-like pain that radiates down
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how large of a stone can be passed
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up to 1cm
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struvite
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stones
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how to clean catch urine
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cleans like normal w/antiseptic wipe
MIDSTREAM note if female is on menses |
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BUN normal range
why would it be elevated |
10-20mg/dL
increased with kidney damage also by DIET, muscle mass/loss |
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serum creatinine normal range
why would it be elevated |
0-1 mg/dL
ONLY IF KIDNEY DAMAGE |
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cystoscopy -what to look for/do
|
-increase fluids if they knock em out
-what for blood (some is normal) 0lots of blood and CLOTS are not |
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how to get urine specimen for culture if indwelling cath
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-clamp tube
-cleanse sampling port or tube -insert needle distal to bifurcation/port |
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2 MAJOR types of urinary diversions
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1) cutaneous -thru the skin
2)continent -part of intestine used as reservoir |
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anastomosed
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surgically connected
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ileal conduit
what is stents aren't draining are any specific meds given/why what does drainage look like reducing smell when to empty |
ureters connected to part of intestines and end of intestine used to make a stoma
MD may order flush of 5-10mL sterile NS ascorbic acid (vit c) to keep pH below 6.5 may see a little blood at 1st then looks like urine but may have some MUCUS d/t bowel avoid eggs,cheese,asparagus use drops or vinegar but NOT ASPIRIN 1/3 full may use a bottle at night |
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new stoma and fitting a bag
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will change in size
measure every 3-6 wks until it stops should fit max 1/8 inch bigger than stoma |
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cutaneous ureterostomy
|
ureters directly out to skin
stoma does not stick out |
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Indiana Pouch
special teaching |
AKA continent ileal urinary reserve
baldder made from ilieum/cecum catheter inserted into stoma PRN must empty at set times and flush 2-3x a day to prevent resorption |
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Knock Pouch
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bowel used to make a bladder with A VALVE use catheter to empty PRN
in males may also connect to urethra |
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Vesicotomy
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stoma made from bladder must use a bag
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nephrostomy
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catheter into renal pelvis that drains into a bag
will often see with a foley cath and the tubes are tied to this to prevent dislodgement |
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utereosigmoidstomy
cons |
ureters into colon
so you "pee out your butt" constant diarrhea reabsorption of electrolytes must empty every 2-3 hrs limit Na d/t hyperchloremic acidosis increase K that is lost in acidosis INFECTION |
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how often to assess a NEW stoma
|
every 4 hours
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what to teach pt about what a normal stoma looks/acts/feels
|
-pink to red and moist
-no nerve endings-no pain -vascular-may bleed when cleaned |
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normal PSA test range
|
<4ng/mL
increased in prostate inlargement |
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BPH
after what age s/s TX |
benign prostatic hyperplasia
40-50 difficulty starting/keeping stream and emptying bladder, nocturia may progress to prostate cancer TURP, Avodart (shrinks it)w/Flomax |
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Prostate Cancer
where does it go |
SLOW grower
more common in AA loves BONE, esp LUMBAR area |
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Tuberculosis of kidney
|
droplets enter lungs then it moves to renal pelvis via blood stream and the immune system walls it off
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prostatitis
|
inflammation of prostate
swollen,tender,warm,firm on digital exam pain in back/penis/groin/scrotum often bacterial infection |
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Robson's system of staging renal carcinoma
Stages:and which are best tx |
1-only in capsule
2-to fat/adrenal gland 3-regional lymph node 4-distant metastasis stages 1 and 2 have best prognosis |
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Vasectomy after sx care
|
-ice to scrotum
-scrotal support -birth control until 2 negative specimens 1 month apart -1st specimen after 15 SHOTS |
