Functions of kidneys:Urine formation, drug excretion, acid base balance, secretion of renin, activation

of vitamin D, production of erythropoiten

Formation of urine:

Glomerular filtration

Tubular reabsorption

Tubular secretion

Describe urination reflex

Destention of the bladder muscle sends sensory impulses to spinal cord which

activate the parasympathetic motor system to contract detrusor muscles & dialate

the internal urethral sphincter allowing it to relax (voluntarly) resulting in urination

What is the point of incontinance in the

urination reflex?The point where the external urethral sphincter relaxes

When is the micturitionreflex activated?It is initiated when 300 to 400 mL of urine form in the bladder, stimulating stretch

receptors within the wall.

Nocturia Urination during the night

Oliguria decreased urination (less than 400mL/24hrs)

Enuresis Bedwetting

Polyuria Excessive urination (more than 2000mL/24 hrs)

Anuria absence of urination

Nursing assessment of Urinary

Elimination

Collection of data about the patient's voiding patterns, habits, and difficulties and

a history of current or past urinary problems

Physical Assessment Nursing of Urinary

Elimination

Palpation of bladder,skin color & texture, vitals, lung sounds, edema, orthostatic

hypotension (<BP/>HR)

What is the normal daily Urine Output 1000 - 2000 mL every 24hrs

Characteristics of Urine; ColorA freshly voided specimen is pale yellow, straw-colored, or amber, depending on

its concentration.

Characteristics of Urine; odorOdor Normal urine smell is aromatic. As urine stands, it often develops an

ammonia odor because of bacterial action.

Characteristics of Urine: TurbidityFresh urine should be clear or translucent; as urine stands and cools, it becomes

cloudy.

Characteristics of Urine: pH

The normal pH is about 6.0, with a range of 4.6 to 8. (Urine alkalinity or acidity

may be promoted through diet to inhibit bacterial growth or urinary stone

development or to facilitate the therapeutic activity of certain medications.) Urine

becomes alkaline on standing when carbon dioxide diffuses into the air.

Characteristics of Urine: Specific gravity This is a measure of the concentration of dissolved solids in the urine. The

normal range is 1.015 to 1.025.

a high specific gravity usually indicates dehydration and a low specific gravity

indicates overhydration.

Renal function tests: Serum Creatintine

Measuring serum creatinine is a useful and inexpensive method of evaluating

renal dysfunction. Creatinine is a non-protein waste product of creatine

phosphate metabolism by skeletal muscle tissue. Creatinine production is

continuous and is proportional to muscle mass

Renal function tests: BUN

Blood urea nitrogen (BUN) measures the amount of urea nitrogen, a waste

product of protein metabolism, in the blood. Urea is formed by the liver and

carried by the blood to the kidneys for excretion.

Adult: 7-20 mg/100 ml

Renal function tests: Uric Acid

Uric acid is the end product of purine metabolism. Purines are obtained from both

dietary sources and from the breakdown of body proteins. Organ meats such as

liver, kidneys, and sweetbreads, sardines, anchovies, lentils, mushrooms,

spinach, and asparagus are all rich sources of purines. The kidneys excrete uric

acid as a waste product.

Renal function tests: Creatinine

clearance

A creatinine clearance test measures the rate at which the kidneys clear

creatinine from the blood. A creatinine clearance test compares the serum

creatinine with the amount of creatinine excreted in a volume of urine for a

specified time. A 24-hour time frame is most common. At the beginning of the

test, the patient empties his bladder and the urine is discarded. Then, all urine

voided during the specific time period is collected

Nursing Diagnoses associated with

Renal Function Tests

Potential Fluid Volume Deficit

Potential fluid volume deficit

Potential alterations in nutritional requirements for specific nutrients - potassium,

sodium, and protein

Cystoscopy

Cystoscopy is the direct visual examination of the bladder, ureteral orifices, and

urethra with a cystoscope. It is used to view, diagnose, and treat disorders of the

lower urinary tract, interior bladder, urethra, male prostatic urethra, and ureteral

orifices

Intravenous Pyelogram (Excretory

Urography)

Intravenous pyelogram is the radiographic examination of the kidney and ureter

after a contrast material is injected intravenously. It is used to diagnose kidney

and ureter disease and impaired renal function.

Retrograde PyelogramRetrograde pyelogram is the radiographic and endoscopic examination of the kidneys

and ureters after a contrast material is injected into the renal pelvis through the ureter.

Renal Ultrasound

A renal ultrasound is a noninvasive procedure that involves the use of ultrasound to

visualize the renal parenchyma and renal blood vessels. It is used to characterize renal

masses and infections, visualize large calculi; detect malformed kidneys; provide

guidance during other procedures, such as biopsy; and monitor the status of renal

transplants and kidney development in children with congenital processes

Renal Biopsy

It is an invasive procedure that involves obtaining a small piece of renal tissue for

microscopic examination. Tissue sample may be obtained by needle and syringe

through a skin puncture or small incision, during an open surgical procedure during

which a wedge of tissue is removed, or through a cystoscope during which a brush is

used to obtain a tissue fragment.

Total incontinence

Continuous and unpredictable loss of urine, resulting form surgery, trauma, or physical

malformation.

Nursing Interventions: Keep skin clean & dry, condom cath

Stress incontinence

Involuntary loss of less than 50mL of urine. r/t increase in intra-abdominal pressure.

Occurs during coughing, sneezing, laughing, or other physical activities. Childbirth,

menopause, obesity, or straining from chronic constipation can also result in urine loss

Overflow incontinence

Involuntary loss of urine is associated with overdistention and overflow of the bladder.

The signal to empty the bladder may be underactive or absent, the bladder fills, and

dribbling occurs. It may be due to a secondary effect of some prostatic or neurologic

conditions

Functional incontinence

is urine loss caused by the inability to reach the toilet because of environmental

barriers, physical limitations, loss of memory, or disorientation.

Common cause in elderly; instituionalized

What are the causes of disorders

of the urinary tract?

Infection, obstructions, cancer, heriditary diseases, chronic disease, traumatic

diseases & metabolic diseases

Factors of UTI's stasis, past history, contamination, female, reflux, instruments, aging

Signs & symptoms of UTI'sDysuria, urgency, frequency, incontinence, hematuria, cloudy, foul smelling urine and

confusion in the elderly

NANDA diagnoses of UTI's

Impaired urinary elimination; frequency

Pain/Discomfort

Health maintenance, altered

Urethral Strictures Narrowing of urethral lumen by scar tissue

Renal Calculi Nephrolithiasis is the formation of crystal aggregates in the urinary tract results in

kidney stones, formed by one of four substances: (1) calcium, (2) uric acid, (3)

magnesium ammonium phosphates (or struvite), or (4) cystine. More common in men,

average onset 30-50yrs often w/ family history/dietary factors.

Signs and symptoms of Renal

Calculi

Pain to the costrovertebral angele, groin, flank, genitala, renal colic. Hematuria, anuria,

restlessness, absent bowel sounds, N/V, diarrhea

Nursing diagnoses for Renal

CalculiAcute pain, risk for infection, deficient knowledge

Hydronephrosis

Distention (dilation) of the kidney with urine, caused by backward pressure on the

kidney when the flow of urine is obstructed. The elevated pressure from obstruction

may ultimately damage the kidney and can result in loss of its function

Signs and symptoms

Hydronephrosis

Can begin quickly causing renal colic, pain, pressure, and distention of the bladder.

Can also start of as asymptomatic & slowly progress

Nursing interventions for

HydronephrosisMonitor I&O,

Glomerulonephritis

Most common following infections by strains of group A, beta-hemolytic streptococci. In

this situation, there is an abnormal immune reaction, causing immune complexes to

become entrapped in the glomerular membrane, inciting an inflammatory response.

The capillary membrane swells and is then permeable to plasma proteins and blood

cells. Usually follows a strep infection by 10 days to 2 weeks (the time needed for

formation of antibodies).

Signs and symptoms

Glomerulonephritis

Oliguria is an early symptom, Na and H20 retention causes edema, particularly of the

face and hands, along with hypertension. Proteinuria and hematuria follow from the

increased capillary permeability. This may give a smoky hue to the urine ("cola"

colored).

Acute Renal Failure

Sudden interruption of kidney function resulting from obstruction, reduced circulation,

or disease of the renal tissue

Results in retention of , fluids; UOP < 400mL/d or 30mL/hr

Build up of toxins on blood: end products of protien metabolism (azotemia). Usually

reversible with medical treatment

May progress to end stage renal disease, uremic syndrome, and death without

treatment

Chronic Renal Failure

Results form gradual, progressive loss of renal function

Occasionally results from rapid progression of acute renal failure

Symptoms occur when 75% of function is lost but considered cohrnic if 90-95% loss of

function

Dialysis is necessary D/T accumulation or uremic toxins, which produce changes in

major organs

Causes of Acute Renal Failure

PRERENAL

Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns,

cardiovascular disorders, sepsis

INTRARENAL

Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney disease

POSTRENAL

Stones, blood clots, BPH, urethral edema from invasive procedures

Stages of Acute Renal Failure

Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP

OLIGURIC PHASE – UOP < 400/d, Longer the phase lasts poorer prognosis

DIURETIC PHASE – UOP ^ to as much as 1-3L/d but no waste products, can not

concentrate urinr, excess waste eliminated in blood

RECOVERY PHASE – things go back to normal or may remain insufficient and

become chronic lasting up to 1 yr

Acute Renal Failure Nursing

interventions

Monitor I/O, including all body fluids

Monitor lab results

Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness,

EKG changes

watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions

Chronic Renal Failure signs and

symptoms

Edema, SOB; cracles, wheezing. Blood vessle distention of neck, may be

polyuric, oliguric, anuric.

Urethral Strictures Narrowing of urethral lumen by scar tissue

Renal Calculi

Nephrolithiasis is the formation of crystal aggregates in the urinary tract results in

kidney stones, formed by one of four substances: (1) calcium, (2) uric acid, (3)

magnesium ammonium phosphates (or struvite), or (4) cystine. More common in

men, average onset 30-50yrs often w/ family history/dietary factors.

Signs and symptoms of Renal CalculiPain to the costrovertebral angele, groin, flank, genitala, renal colic. Hematuria,

anuria, restlessness, absent bowel sounds, N/V, diarrhea

Nursing diagnoses for Renal Calculi Acute pain, risk for infection, deficient knowledge

Hydronephrosis

Distention (dilation) of the kidney with urine, caused by backward pressure on the

kidney when the flow of urine is obstructed. The elevated pressure from

obstruction may ultimately damage the kidney and can result in loss of its

function

Signs and symptoms Hydronephrosis Can begin quickly causing renal colic, pain, pressure, and distention of the

bladder.

Can also start of as asymptomatic & slowly progress

Nursing interventions for

HydronephrosisMonitor I&O,

Glomerulonephritis

Most common following infections by strains of group A, beta-hemolytic

streptococci. In this situation, there is an abnormal immune reaction, causing

immune complexes to become entrapped in the glomerular membrane, inciting

an inflammatory response. The capillary membrane swells and is then permeable

to plasma proteins and blood cells. Usually follows a strep infection by 10 days to

2 weeks (the time needed for formation of antibodies).

Signs and symptoms Glomerulonephritis

Oliguria is an early symptom, Na and H20 retention causes edema, particularly of

the face and hands, along with hypertension. Proteinuria and hematuria follow

from the increased capillary permeability. This may give a smoky hue to the urine

("cola" colored).

Acute Renal Failure

Sudden interruption of kidney function resulting from obstruction, reduced

circulation, or disease of the renal tissue

Results in retention of , fluids; UOP < 400mL/d or 30mL/hr

Build up of toxins on blood: end products of protien metabolism (azotemia).

Usually reversible with medical treatment

May progress to end stage renal disease, uremic syndrome, and death without

treatment

Chronic Renal Failure

Results form gradual, progressive loss of renal function

Occasionally results from rapid progression of acute renal failure

Symptoms occur when 75% of function is lost but considered cohrnic if 90-95%

loss of function

Dialysis is necessary D/T accumulation or uremic toxins, which produce changes

in major organs

Causes of Acute Renal Failure

PRERENAL

Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns,

cardiovascular disorders, sepsis

INTRARENAL

Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney

disease

POSTRENAL

Stones, blood clots, BPH, urethral edema from invasive procedures

Stages of Acute Renal Failure Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP

OLIGURIC PHASE – UOP < 400/d, Longer the phase lasts poorer prognosis

DIURETIC PHASE – UOP ^ to as much as 1-3L/d but no waste products, can not

concentrate urinr, excess waste eliminated in blood

RECOVERY PHASE – things go back to normal or may remain insufficient and

become chronic lasting up to 1 yr

Acute Renal Failure Nursing

interventions

Monitor I/O, including all body fluids

Monitor lab results

Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle

weakness, EKG changes

watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions

Chronic Renal Failure signs and

symptoms

Edema, SOB; cracles, wheezing. Blood vessle distention of neck, may be

polyuric, oliguric, anuric.

Chronic Renal failure pathophysiology

EARLY STAGE: Diminished renal reserve 50% nephron loss

Kidney function is mildly reduced while the excretory and regulatory function are

sufficiently maintained to preserve a normal internal environment. The patient is

usually problem free.

RENAL INSUFFCIENCY:75% impaired renal capacity decreased urinary

concentrating ability, anemia, BUN/creatinine levels increase. Factors that can

exacerbate the disease at this stage by increasing nephron damage are:

infection, dehydration, drugs

ESRD:90% of the nephrons are damaged Renal function has so deteriorated that

chronic and persistent abnormalities; Uremic Syndrome

Patient requires artificial support to sustain life, i.e. dialysis, transplant

Chronic Renal failure electrolyte

distubances

Na+2 - Hypernatriemia >145mEq/L: fever, restless, increased fluid retention,

^BP, edema, decreased UOP

- hyponatremia

<135mEq/L lethargy, headache, CONFUSION, seizures

K+ - Hypokalemia

<3.5mEq/L fatigue, weak irregular pulse, poly uria, hyperglycemia, bradiacardia

- Hyperkalemia

>5.5mEq/L muscle weakness, urine changes (oliguria or anuria), respiratory

distress, decreased cardiac contrantibility, EKG changes, reflexes flaccid

Ca+2 - Hypercalcemia

>11mg/dl anorexia, N/V, fatigue, constipation, dehydration, bradycardia

- Hypocalcemia

<8.5mg/dl convulsions, arrythmias, tetny,and spasms

Chronic renal failure symptoms:

Disturbance in removal of waste products - azotemia: weakness, fatigue,

confusion, N/V, urea crystals (itching skin)

Disturbance in maintaining acid/base balance - Kussmaul’s respirations (deep &

fast) from acidosis, headache, N/V, fatigue, weakness

Disturbance in hematolgic function -anemia, decrease in RBC survival time

Chronic Renal Failure Theraputic

Interventions:

Fluid and dietary restrictions

Maintain E-lytes

Dialysis to jump start renal function

May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.

Ace inhibitors, calcium channel blokers > hypertension

Renal Failure Nursing Diagnoses

Skin integrity impairment, Potential alterations in nutritional requirements,

Potential Fluid Volume Deficit, Potential for injury related to weakness and

confusion

Uremic SyndromeA cluster of symptoms related to the retention of nitrogenous substances in the

blood. Symptoms include: fatigue, confusion, N/V, diarrhea, gastritis, itchy skin

Pre-End Stage Renal Disease Diet

Guidelines

PROTIEN & PHOSPHORUS restriction SLOWS progression.

Protien - 0.6 to 1.0g/kg of ideal body weight. <5-6oz (men) & <4oz (women)

Phosphorus - 8-12mg/kg ideal weight or Limit milk to 1/2 cup, 1oz cheese or any

other high phosphorus foods to 1 serving per day.