formation of urine excretion or conservation of water electrolyte balance acid-base balance ...
TRANSCRIPT
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Formation of Urine Excretion or Conservation of Water Electrolyte Balance Acid-base Balance Activation of Vitamin D Production of Erythropoietin Production of Renin
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Glomerular filtration Glomerular filtration rate Tubular reabsorption
› Include water and electrolytes Tubular secretion Urine concentration
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Renal Filtrate Kidneys form in 1 minute Averages 100-125 mL/minute
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Renin-angiotensin-aldosterone system› Role in blood pressure and sodium
reabsorption Erythropoietin
› Role in RBC production Vitamin D and calcium regulation Acid-base balance
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Ureters: carry urine from kidneys to bladder
Bladder: temporary storage of urine and its elimination
Urethra: carries urine from bladder to exterior
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Amount: 1000-2000 mL/24 hours Color: straw or amber Clarity: clear Specific Gravity: 1.010-1.030
› Lower=Dilute; Higher=Concentrated pH: 4.6-8.0
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Constituents› 95% water› Waste products: Urea, Creatinine, Uric Acid
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Renal Mass Smaller Renal Flow Decreased 50% Decreased Tubular Function Bladder Muscles Weaken Bladder Capacity Decreases Voiding Reflex Delayed Nephrons lost with aging
› Reduces kidney mass and GFR Less urine concentration
› Risk for dehydration
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Health History Pain/Burning with Voiding New Onset Edema, Shortness of
Breath, Weight Gain Fluid Intake Functional Ability
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Color, clarity, amount of urine Difficulty initiating urination or changes
in stream Changes in urinary pattern Dysuria, nocturia, hematuria, pyuria
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Vital Signs Lung Sounds Edema Daily Weights Intake and Output Skin Assessment
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Urinalysis› Common test› Voided or Cath Specimen
24 hour Clean catch
› 10 mL of urine collected› Color, odor, clarity
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Urine Culture› Identifies bacteria present› Urine collected before antibiotics› Sensitivity test determines antibiotic that
will destroy bacteria
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Renal Function Tests› Serum Creatinine› Blood Urea Nitrogen› Uric Acid› Creatinine Clearance Test
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Kidneys-Ureter-Bladder› Show tumors, swollen kidneys, kidney
stones
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Intravenous Pyelogram› Dye injected› Dye outlines renal structures› Check allergies› Increase fluids afterward
Renal Angiography› Dye visualizes renal arteries› Check allergies
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Cystoscopy and Pyelogram› Surgery: Cystoscope inserted in bladder
through urethra› Pyelogram: dye injected in kidney pelvis› X-rays taken
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Noninvasive sound waves examine anatomy of urinary tract
Shows kidney enlargement, kidney stones, chronic infection, tumors
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Percutaneous or Open Before - NPO, Mild Sedative
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After› Vital signs› Observe for bleeding
Biopsy site, Urine
› Pressure dressing, sandbag› Bed rest for 24 hours
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Types› Stress› Urge› Functional› Overflow› Reflex
total
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Postvoid residual urine Ultrasonic bladder scan Cystometrography Uroflowmetry
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Medications› Inhibit detrusor muscle contractions› Increase bladder capacity› Estrogen therapy
Surgery› Bladder neck suspension› Prostatectomy
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Impaired Urinary Elimination Toileting Self-Care Deficit Social Isolation
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Evaluating› Keep voiding diary› Identify wetting episodes› Assess willingness to participate in social
activities Teaching
› Home environment› Voiding diary› Therapies
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Occurs when bladder cannot empty May be caused by obstructive or
functional problem› Benign prostatic hypertrophy› Surgery› Drugs› Neurologic diseases› Trauma
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Acute› Anesthesia, medications, local trauma to
urinary structures Chronic
› Enlarged prostate, medications, strictures, tumors
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Manifestations› Overflow voiding› Incontinence› Firm, distended bladder
May be displaced
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Monitor› Urine output› Bladder distention› Bladder Scan
Residual volume of 150-200 cc urine Indicates need for treatment
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Complications› Hydronephrosis› Acute renal failure› Urinary tract infection
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Diagnostic tests› Portable bladder scan
Treatment depends on cause› Surgery› Medications› Stimulation techniques› Catheterization
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Identify clients Take measures to promote urination
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Indwelling Catheters› Justifiable reasons
Shock Urinary tract obstruction Neurogenic bladder
› Urinary incontinence is NOT justification Urinary catheters result in infection
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Intermittent catheterization› Best› Reduces risk of infection› Patients may self-cath
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Suprapubic Catheter› Indwelling catheter inserted through
incision in lower abdomen into bladder
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Invasion of urinary tract by bacteria Women > Men Aging
› Older men due to enlarged prostate› Women due to declining estrogen› Nosocominal infections common
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Stasis of urine Contamination in Perineal/Urethral area Instrumentation Reflux of urine Previous UTIs
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Dysuria Urgency Frequency Cloudy, foul-smelling urine
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Urethritis: inflammation of urethra Cystitis: inflammation/infection of
bladder wall Pyelonephritis: infection of the kidneys
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Dysuria, flank pain, fever, chills, malaise
Urine examined for cloudiness, blood, foul odor
Predisposing factors Urinalysis and culture results
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Urinalysis Urine culture & sensitivity CBC with differential IP Voiding cystourethrography Cystoscopy
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Acute pain Impaired urinary elimination Risk for injury Knowledge deficit
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Monitor symptoms Monitor intake and output Pain control Teaching
› Medications: take all antibiotics – 3-7 days› Prevention
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Obstruction of urine flow is always significant
Backup of urine destroys kidney
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Urethral Strictures› Urethra lumen narrowing due to scar tissue
Renal Calculi› Hard, generally small stones› Kidney stones
Nephrolithiasis
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Urolithiasis most common cause of obstructed urine flow
Calculi› Masses of crystals formed from materials
normally excreted in urine› Most made from calcium
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Etiology› Heredity› Chronic dehydration› Infection› Immobility› Men > Women
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Kidney/Pelvis› May be asymptomatic› Dull, aching flank pain
Ureter› Acute severe flank pain, may radiate› Nausea/vomiting› Pallor› Hematuria
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Bladder› May be asymptomatic› Dull suprapubic pain› Hematuria
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Diagnosis› Kidney-ureter-bladder x-ray› Intravenous Pyelogram (IVP)› Renal ultrasound› Urinalysis
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Small stones passed IV fluids Pain control Thiazide diuretics Allopurinol Lithotripsy
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Medications Dietary management Surgery
› Lithotripsy› ESWL› Cystoscopy› Nephrolithotomy› Nephrectomy
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Prevention› Foods› Hydration› Exercise
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Complications› UTIs› Hydronephrosis
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Nursing Diagnosis› Acute pain› Risk for infection› Deficient knowledge
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Monitor symptoms Strain all urine Intake and output Pain control Hydration Teaching
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Abnormal dilation of renal pelvis and calyces
Results from urinary tract obstructions or backflow of urine
Manifestations depend on how rapidly it develops
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Diagnosis› Ultrasound› CT scan› Cystoscopy
Treatment› Stents
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Signs and symptoms› Frequency› Urgency› Dysuria› Flank and back pain› Renal failure
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Treat cause Urinary catheter Stents Nephrostomy tube
› Intake and output› No clamping
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Focuses on prevention and ensuring urinary drainage
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Most common urinary tract cancer Men > Women Ages 50-70 years Etiology
› Smoking› Industrial pollution
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Signs and symptoms› Early
Painless Hematuria
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Signs and symptoms (cont’d)› Late
Pelvic pain Lower back pain Dysuria Inability to void
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Diagnosis› Urinalysis
Telomerase
› Urine for Cytology, Culture› Cystoscopy and Transurethral Biopsy› IVP
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Therapeutic Interventions› Chemotherapy› Bacille Calmette-Guérin Vaccine› Photodynamic Therapy
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Therapeutic Interventions› Surgery
Cystoscopy & Pyelogram with Fulguration Laser Robotic Laparoscopic Radical Cystectomy Urinary diversion
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Therapeutic Interventions› Incontinent urinary diversion
Ileal conduit
› Continent urinary diversion Kock pouch
› Othotopic bladder substitution Studer pouch Hemi-Kock pouch Ileal W-Neobladder
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Nursing Care› WOC Nurse› Monitor urine output› Education› Preop and postop care
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Uncommon Renal cell carcinoma most common
primary tumor Risk factors
› Smoking› Obesity› Renal calculi› Hypertension› Long term kidney dialysis› Radiation exposure› Asbestos› Industrial pollution
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Most arise from tubular epithelium Can occur anywhere Often metastasize Often silent
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Later signs and symptoms› Hematuria› Dull pain in flank area› Mass
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IVP Cystoscopy and Pyelogram Ultrasound CT scan MRI Renal biopsy
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Therapeutic Interventions› Radical Nephrectomy› Nephron-sparing surgery› Radiation therapy› Immunotherapy› Chemotherapy
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Nursing Management› Monitor urine output› Education› Preop and postop care
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Pain Ineffective breathing pattern Risk for impaired urinary elimination Anticipatory grieving
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Flank pain Hematuria Treat injury
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Nursing Care› I & O› Vital signs› IV fluids› Pain control
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Multiple cysts in the kidney Signs and symptoms
› Dull heaviness in flank/back› Hematuria› Hypertension› UTI
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Progressive No treatment
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Long-term complication of diabetes Most common cause of renal failure Atherosclerotic changes decrease blood
to kidney Smaller doses of insulin as progresses Chronic renal failure develops
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Inflammatory condition of glomerulus Acute or chronic Primary kidney disorder or secondary
to systemic disease
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Affects structure and function of glomerulus
Damages capillary membrane› Blood cells and proteins escape into filtrate› Hematuria, Proteinuria, Azotemia
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Usually follows infection of group A beta-hemolytic Streptococcus
Manifestations develop abruptly Hematuria, proteinuria, edema,
hypertension, fatigue Anorexia, nausea, vomiting, headache Elevated BUN and serum creatinine
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Older adults may show less characteristic manifestations
Symptoms may subside spontaneously Some may develop chronic
glomerulonephritis
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Usually end-stage kidney damage Slow, progressive destruction of
glomeruli Gradual loss of nephrons Kidneys decrease in size Symptoms develop slowly
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ASO titer ESR BUN Serum creatinine
Serum electrolytes Urinalysis KUB x-ray Kidney scan or
biopsy
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Signs and symptoms› Oliguria› Hypertension› Electrolyte imbalances› Edema› Flank pain
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Focus is on identifying and treating underlying disease process and preserving kidney function
Medications Plasma exchange therapy Dietary management Renal failure treatment
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Vital signs Symptom support Rest Fluid, sodium, protein restrictions Renal failure care Education
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Preventing acute renal failure is goal of care
Diagnostic tests› Serum creatinine, BUN› Creatinine clearance› Serum electrolytes, ABGs, CBC› Urinalysis› Kidney biopsy
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Kidneys unable to remove waste products from blood
Acute or chronic Azotemia
› Waste products accumulate Fluid, electrolyte, acid-base imbalances
› Oliguric
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Rapid decline in function Abrupt onset Often reversible with treatment Risk factors
› Major trauma, surgery, infection, hemorrhage, severe heart failure, lower urinary tract obstruction
› Older adults at risk
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Prerenal Failure› Decreased blood supply to kidneys
Intrarenal Failure› Damage to nephrons
Postrenal Failure› Obstruction
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Nephrotoxins› Diagnostic Contrast Media (Dyes)› Medications
IV Aminoglycosides, Tobramycin (Tobrex), Amikacin (Amikin), Cisplatin (Platinol)
› Chemicals
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Prevention› Check serum BUN and creatinine prior to
dyes or meds› Hydrate before/after contrast media› Monitor peak/trough levels of nephrotoxic
drugs per institutional policy
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Phases› Oliguric› Diuretic› Recovery
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Therapeutic Interventions› Treat cause› Supportive treatment› Dialysis› Continuous renal replacement therapy
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Removes fluid continuously along with Hemodialysis
Remove fluid/solutes in controlled, continuous manner in unstable patients
Blood flows through Hemofilter, excess fluids/solutes move into collection bag
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Gradual decrease in kidney function Irreversible Slow, insidious process Final stage is end-stage renal disease Increasing in incidence Diabetic nephropathy and hypertension
leading causes in U.S.
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Etiology› Diabetic Nephropathy› Nephrosclerosis› Glomerulonephritis› Autoimmune diseases
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Nephrons destroyed by disease process Remaining nephrons hypertrophy and
have increased workload› Can compensate for a while
Renal insufficiency develops – 75% of nephrons lost
Further insult leads to ESRD› Uremia develops
End-stage: 90% of nephrons lost Uremia: urea in the blood Affects all body systems
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Often not identified until uremia develops› Nausea› Apathy› Weakness› Fatigue› Confusion
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Fluid accumulation Electrolyte imbalance Waste products retained Acid-base imbalance Anemia
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Diet› High calorie› Low protein (unless dialysis)› Low sodium, potassium, phosphorus› Increased calcium› Vitamins
Fluid restrictions
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Medications› Diuretics› Antihypertensives› Phosphate binders› Calcium/Vitamin D supplements› Kayexalate prn
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Dialysis› Symptoms of fluid overload› High potassium› Neurological signs› Uremia
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Hemodialysis› Artificial kidney removes waste products
and excess water from blood
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Vascular Access› Temporary› LifeSite Hemodialysis Access System› A-V Graft› A-V Fistula
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Vascular Access Care› Thrill, Bruit› Protect› Postop
NV checks, pain Elevate extremity
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Continuous dialysis done by patient Peritoneal membrane is
semipermeable membrane, across which excess wastes/fluids move from blood
Peritoneal catheter Exchange process: fill, dwell time, drain
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Excess fluid volume Imbalanced nutrition: less than body
requirements Risk for infection Disturbed body image Activity intolerance Impaired skin integrity Risk for injury
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Excess fluid volume› Monitor weight› I & O› Fluid restriction› Monitor for fluid retention
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Electrolyte imbalance› Monitor levels› Dietary restriction› Monitor dysrhythmias
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Waste products› Oral care, skin care› Lotion› Protect from injury
Impaired hematological function› Protect from injury/infection
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BPH tends to occur in men over 40 years of age
Intervention is required when symptoms of obstruction occur
The most common treatment is transuretheral resection (TURP)
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PSA› False high levels can be present for up to
12 days after a rectal examination or instrumentation around the prostate gland especially after a cystoscopy
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Signs and symptoms› Increased frequency with a decrease in
amount of each voiding› Nocturia› Hesitancy› Terminal dribbling› Decrease in size and force of stream› Acute urinary retention› Bladder distention
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TURP› Preop teaching› Monitor urinary drainage system› Provide pain relief› Monitor urinary drainage system for clots› Irrigate bladder as prescribed› Monitor H &H› Monitor v/s
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Hematuria generally is present for at least 23 hours following a TURP
Monitor color & content of urinary output
Care post catheter removal› Monitor # of voids and amount› Have client collect urine in specimen cups
Force fluids