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RENAL AND URINARY DISORDERS

Anatomy of renal/urinary system

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Urinary System Anatomy

2 kidneys
Nephron Blood vessels Formation of urine Glomerular filtration (*dependent on BP & perfusion) Tubular reabsorption Tubular secretion

2 ureters Urinary bladder Urethra

Urinary System Function

Removal of toxic waste products Regulation of blood volume Regulation of electrolyte balance Regulation of acid-base balance Regulation of fluids/electrolytes in tissue fluid Production of erythropoietin*

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Age related changes

Urinary bladder
Decreased bladder size & tone of detrusor muscle

Kidneys
Decreased ability to concentrate urine GFR decreases Nephrons decrease

Males
Enlarged prostate

Females
Pelvic floor muscle weakness Prone to bladder infections, urinary incontinence, & urethral irritation

Changes in Amount or Color of Urine

POLYURIA= >60 cc/hour urine output common in DM, DI, and use of drugs OLIGURIA=100-500cc/day urine output common in ARF, shock, dehydration and F&E imb. ANURIA =<50 cc/day or no urine output due to obstruction or other disease

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Changes in Amount or Color of Urine

Hematuria Blood in the urine=serious sign and requires evaluation
Dark, rusty urine=bleeding from upper ureters (GROSS) Bright red bloody urine=bleeding from lower ureters (MICROSCOPIC) hematuria=bleeding from renal parenchyma Painless hematuria=may indicate neoplasm in the BLADDER

Changes in Amount or Color of Urine

PNEUMATURIA=passage of gas in urine during voiding caused by bowel and bladder fistula rectosigmoid cancer, regional ileitis, sigmoid diverticulitis (common) and gas forming UTI PROTEINURIA=presence of CHON in the urine KETONURIA=presence of ketone bodies in the urine AZOTEMIA=build up of nitrogenous waste products in the blood UREMIA=presence of uric acid in the blood

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Symptoms Related to Irritation of the Lower Urinary Tract

DYSURIA=pain or difficult urination (UTI=burning sensation)

Frequency=voiding occurs more often than usual (normal=once every 3-6 hours)
Urgency=strong desire to urinate that is difficult to control due to inflammation of the bladder, prostate and urethra. Nocturia =excessive urination at night that interrupts sleep Strangury =slow and painful urination, only small amount of urine is voided (cystitis)

Symptoms Related to Irritation of the Lower Urinary Tract

Pain: During and after voiding=bladder Flank=kidneys and ureters Start of voiding=urethra

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Symptoms Related to Obstruction of the Lower Urinary Tract

Weak Stream=decreased force of stream

Hesitancy=undue delay and difficulty in initiating voiding (neurogenic bladder)

Terminal Dribbling=prolonged dribbling of urine from the meatus after urination is complete Incomplete emptying=feeling that the bladder is still full even after urination. May lead to infection.

Types of Urinary Incontinence

INCONTINENCE=involuntar y loss of urine may be due to pathologic, anatomical or physiologic factors.
STRESS=intermittent leakage of urine due to increased abdominal pressure (coughing, straining and sneezing) URGE=sensation of the need to urinate followed by sudden involuntary loss of urine

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Types of Urinary Incontinence

OVERFLOW= loss of urine caused by overdistention of the bladder.

TOTAL = continous leakage of urine due to injury of the sphincteric mechanisms, bladder and urethra.
FUNCTIONAL = loss of urine due to functional impairment (inability to go to the bathroom or positioned to void) MIXED = combination of two or more types of incontinence ENURESIS = involuntary voiding during sleep (obstructive or neurogenic)

Laboratory Procedures

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Collection of Urine Specimen

Random Urine Sample Urine Straining
Clean Urinalysis Exam

24 Urine Collection

Clean To collect stone

Clean Catch Urine

Clean To monitor urine output and creatinine clearance Sterile Culture and Sensitivity Test Sterile Culture and Sensitivity Test Catheterization Sterile

Mid-stream Catch Urine

Urinalysis
It involves overall characteristics of urine: Appearance Normal urine is clear Cloudy=due to pus, blood, bacteria and lymph fluid Odor Normal is faint aromatic odor Offensive odor=bacterial action

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Urinalysis
Color Normal is clear yellow or amber Straw colored = diluted Highly colored = concentrated urine due to insufficient fluid intake Cloudy or smoky = hematuria, spermatozoa Red or red brown = bleeding or drugs and food Yellow-brown or green-brown = obstructive jaundice or lesion from bile duct Dark-brown or black = malignant melanoma or leukemia

Urinalysis
pH Maintain normal hydrogen ion concentration in plasma and ECF Must be measured in fresh urine because the breakdown of Urine to ammonia causes urine to become alkaline Normal pH is around 6 (acid) or 4.6-7.5 Specific gravity Reflects ability of the kidneys to concentrate or dilute urine, Normal range is from 1.015-1.030 Osmolality More precise test than specific gravity 1-2 ml urine are required Normal range is from 300-1090 mOsm/L (number of particles per unit volume of water)

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Urinalysis
Protein Proteinuria 150 mg/24 hrs may indicate renal disease 24 hour urine Can be affected by protein intake Urine casts (tiny deposits of substances on the walls of renal tubules) RBC=glomerulonephritis Fatty casts=nephrotic syndrome WBC=pyelonephritis, collect random urine specimen Organic waste (solute of urine)=urea, creatinine, ammonia and uric acid Inorganic waste (solute of urine)=Na, K, Cl, SO4 and P

Catheterization
Done to relieve acute or chronic urinary retention Drain urine pre/postoperatively Determine the amount of residual urine after voiding For accurate measurement of urinary drainage in critically ill patient (strict intake and output) Suprapubic (incision on the abdomen) Done for acute urinary retention when urethral catheterization is not possible To obtain an uncontaminated urine sample

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Catheterization
Coude (for constricted or stenosed urethra) Straight cath (intermittent cath) Indwelling cath/foley cath (strict I&O) 3 way cath (cystoclysis, 3 way bladder irrigation)

Catheterization
Continuous bladder irrigation Irrigation, drainage, inflation port (3 ports) Done after prostate resection Initial drainage must be Avoid clot formation in the drainage if drainage suddenly stops look for obstruction or kinking of the tube If there is no drainage in the absence of kinking, suspect blood clot
pinkish in color (normal) bloody (abnormal)

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Urinary Diversion
Vesicostomy The bladder is sutured to the abdominal wall and creates an opening

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Urinary Diversion
Nephrostomy Renal pelvis is catheterized and brings it out to the skin

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Urinary Diversion
Cutaneous Ureterostomy > Detached ureter is surgically positioned to an opening in the skin

Urinary Diversion
Ileal Conduit Cut section of the ileum is surgically placed in the abdomen Stoma must be pinkish and moist Clean stoma with soap and water. Keep it dry. Avoid urine contact to the skin Use vinegar for cleaning the bag Cover the stoma when cleaning with gauze pad

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Urinary Diversion
Colon Conduit The ureters are attached to the colon Increased risk of infection

Creatinine Clearance Test (urine specimen)

Measures the rate of kidneys ability to clear creatinine from the blood 24 hour urine collection then draw one sample of blood within the period Most sensitive test for renal disease GFR assessment 24 hour urine collection to detect renal disease Discard first voided urine in the morning and start the collection process Refrigerate all collected urine immediately to avoid contamination

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Test of Renal Function

To check renal excretory functions There is no single test of renal function, best results are obtained by combining a number of clinical tests Renal function is variable from time to time Renal function may be within normal limits until 50% of renal function is lost.

Blood Studies
Blood Urea Nitrogen BUN primary end product of protein metabolism and is excreted by the kidneys an elevation of BUN may indicate impaired kidneys not specific for the kidney function normal value=10-20 mg/dl

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Serum Creatinine specific for renal function test not affected by dietary intake or hydration status normal value 0.5-1.5 mg/dl elevated in cases of glomerulonephritis Pyelonephritis, acute tubular necrosis, nephrotoxicity, renal insufficiency and renal failure. not reabsorb by the kidney tubules

Blood Studies

Blood Studies
Serum Electrolytes
All electrolytes will elevate except calcium in CRF

CBC
RBC count is reduced in CRF

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Radiology and Imaging

These tests include simple xrays X-rays with the use of contrast media, UTZ, nuclear scans, imaging through computed tomography and MRI

UTZ
Ultrasound=KUB assessment Full bladder during the test Previous barium studies may affect the test Useful in differentiating between solid and fluid filled mass Detect mass, obstruction and malformations

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Retrograde Urography
Alternative procedure if the client is allergic to injectable contrast medium Contrast media is administered directly into the urinary tract via cystoscope rather than IV administration

Endoscope
Visualization via cystoscopy (direct visualization of the urinary bladder via cystoscope) Used to evaluate recurrent UTI, vesicourethral reflux, and hematuria After the test increase fluid intake and watch out for infection

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Endoscopic Procedures
Endoscope=an illuminated optic/sight for visualization Scopy=visualization Cystoscopy=bladder Ureteroscopy=ureter Nephroscopy=renal pelvis Ureterorenoscopy=ureter to the level of calices Cystogram=radiograph produced by cystography Cystography=radiographic examination of the urinary bladder after introduction of a dye Cystourethrogram=radiograph produced by cystourethrography Cystourethrography=radiographic examination of the urinary bladder and urethra after introduction of a dye Ureterogram=injection of dye into the ureter Ureterography=radiologic visualization of the ureter using a dye Vesiculogram=introduction of contrast media into the deferent ducts Vesiculography=seminal vesicles and adjacent tissue

Radiologic films KUB are taken after an injection of contrast media. Can detect stone masses hematuria, obstruction and congenital anomalies Check allergies from the contrast media, flushing, warmth and unpleasant, salty taste may be experienced when the dye is administered. Monitor hydration after the IVP NPO night before the test Cleanse the bowel prior to the test

Intravenous Pyelography IVP or Excretory Urography

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Renal Angiography or Renal Scan

Radiographic visualization of renal blood vessels, size, shape and function after an introduction of a contrast media Used to evaluate renal tumors, vascular map pre-op and potential kidney donor NPO 6-8 hours

MRI (with injection of contrast media)

To image renal anatomy To diagnose tumors, infarcts, vascular malformations and other abnormalities Patient is placed under a strong magnetic field Test is similar to x-ray although it uses no radiation Painless and lasts 15-30 minutes No food or fluid restrictions Contraindicated to patient with metal in and on the body: pacemakers, metallic clips, prosthetic heart valves Claustrophobic patient must be noted

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CT Computed Tomography
100x sensitive to ordinary radiograph Can evaluate kidneys, urinary tract trauma, transplanted kidney, renal calculi and infection, painless procedure.

Renal Biopsy
Supine position Hold breath when the kidney is about to be punctured Bleeding time must be checked before the test Prone position after the test Avoid palpation and manipulation on the area Avoid strenuous activity 2-3 weeks after the test Monitor complication: Colicky pain=clot in the ureter Flank pain=bleeding in the muscle Evaluate hematuria=collect serial urine specimen

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URINARY CALCULI
Presence of stones in the urinary tract One of the most common urologic problems
Stones form when chemicals and other elements of urine become concentrated and form crystals; usually related to METABOLIC or DIETARY causes.

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These are the types of stones.

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RISK FACTORS!!!
DEHYDRATION

INFECTION
OBSTRUCTION
METABOLIC FACTORS
Hypoparathyroidism Renal tubular necrosis Uric acid levels Defective oxalate metabolism Excessive Vit. D or dietary calcium intake

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ASSESSMENT
PAIN: Flank pain on side of affected
Nausea and vomiting Abdominal distention Fever and chills
kidney; may radiate to groin (RENAL COLIC)

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DIAGNOSTIC & LABS

Urinalysis 24-hour urine collection Serum levels for Ca+, phosphorus, uric acid Chemical analysis of stones for content and type KUB, IVP, retrograde pyelography, UTZ, CT scan, cysttoscopy, MRI

THERAPEUTIC MANAGEMENT
EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY (ESWL)

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TREATMENT FOR CALCIUM PHOSPATE and/or OXALATE STONES

with limitations of foods high in Ca+ and oxalates

ACID-ASH DIET

ACID-ASH DIET
Cranberries Plums Grapes Prunes Tomatoes Eggs and cheese Whole grains Meat and poultry

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ALKALINE-ASH DIET
Legumes Rhubarb, milk and milk products Green vegetables Fruits except those mentioned in the acid-ash diet

TREATMENT FOR URIC ACID STONES

ALKALINE-ASH and LOW PURINE DIET

TREATMENT FOR CYSTINE STONES

ALKALINE-ASH DIET

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NURSING DIAGNOSES

PAIN
IMPAIRED URINARY ELIMINATION DEFICIENT KNOWLEDGE

RISK FOR INFECTION

URINARY RETENTION

Urinary Retention

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Urinary Retention
Inability to empty the bladder that leads to bladder distention Poor contractility of the detrussor muscle Mechanical obstruction of bladder outlet (BPH or acute inflammation) Functional problems
Post op Medications: Anticholinergics, antidepressants, antipsychotic, anti-Parkinson, antihistamines, some antihypertensives

Urinary Tract Infection (UTI)

Most common- nosocomial UTIs can affect any portion of urinary tract
ex. lower urinary tract infections = urethritis, prostatitis, cystitis

Most common upper urinary tract infection = pyelonephritis (inflammation of kidney and renal pelvis)
Urinary tract is normally sterile above the urethra Bacteria from intestines (E-coli) = UTI

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RISK FACTORS!!!
Catheterizations or indwelling Foley caths*** Obstructions, strictures Incomplete bladder emptying Diabetes Tissue trauma Contamination during sexual intercourse Voluntary urinary retention (keep holding it) Enlarged prostate Diaphragm for birth control **Poor personal Hygiene practices, and not wiping from front-back

CYSTITIS
Inflammation of bladder
Most common UTI obstruction of urethra or ascending infection most common cause Inflammation process causes classic manifestations (s/s)
Dysuria, urgency, nocturia, pyuria=pus and cloudy urine, with odor, hematuria=bld.

Older adults may be asymptomatic Present with confusion, lethargy, behav. changes, anorexia, just not feeling right.

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Urethra is short and straight

Urinary meatus is close to the vagina and anus

How would you respond to a female client who asks you why she seems to have more UTIs compared to her husband?

Tissue trauma and potential complication occurs during sexual intercourse Poor personal hygiene and voluntary urinary retention

AGING because of prostatic hypertrophy

Pyelonephritis: *KIDNEY INFECTION

Acute/chronic
Bacteria (E-coli-**) usually enters via lower urinary tract Common in children/adults

S/S acute pyelonephritis

rapid w/ chills, fever, malaise, vomiting, flank pain/back pain *older adults = change in behavior, incontinence, confusion, (may be no fever)
Chronic form= lead to fibrosis, scarring, renal failure

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Affects the renal pelvis and parenchyma

Infection develops in scattered areas and spreads from renal pelvis to cortex edematous kidney + abscesses E. Coli causes 85% of cases; Acute form is bacterial infection (usually caused by bacteria that ascend from lower UTI) Chronic form is associated with nonbacterial infections noninfectious processes = METABOLIC, CHEMICAL, IMMUNOLOGIC DISORDERS VESICOURETERAL REFLUX: urine moves from bladder back toward the kidneys) is a common risk factor in children who develop pyelonephritis

AUTOIMMUNE PROCESS

INFLAMMATION

SCARRING OF TISSUE

FIBROSIS

CHRONIC RENAL FAILURE and ESRD

GRADUAL DESTRUCTION OF TUBULES

DILATION OF RENAL PELVIS

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Inflamed pelvis

Dilated ureter

PYELONEPHRITIS

NORMAL KIDNEY

Contrast-enhanced CT image in a 71-year-old diabetic woman with clinical findings of acute pyelonephritis shows markedly swollen kidneys with hypoattenuated lesions (arrowheads) in papillary regions and, at the right kidney periphery, a wedge-shaped lesion (black arrowheads)

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Diagnostics & Treatment of UTI

DX: urinalysis via mid-stream clean catch or a straight-catheterization (in and out cath), CBC/WBC.
Uncomplicated UTI=

antibiotics, drugs such as sulfa based drugs (if not allergic), ex. Septra, Bactrim, DS, Gantrisin, Cipro urinary analgesic=*Pyridium=turns the urine *orange-reddish-use not more than 48 hrs.(stain clothes) yellow tinged skin or sclera=toxicity and call the physician

Empty bladder frequently q 2-4 hrs/ force fluid intake to 2-3L of fluid or water, cranberry juice = maintain acidic urine (no orange juice,* vit C tabs ok), Clean from front-back, men cleanse foreskin, void after sex, wear cotton underwear, avoid bubble baths/ feminine sprays, Reduce intake of sugar, ETOH, and fat

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HYDRONEPHROSIS/NEPHROSTOMY
Hydronephrosis- condition resulting from untreated obstruction in the urinary tract Usually treatable Obstruction of urine can be from tumor, enlarged prostate, kidney stones Stent placement- to hold open Nephrostomy tube may be inserted directly into kidney pelvis to drain UA

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NEPHROSTOMY Renal pelvis is catheterized and brings it out to the skin

SUPRAPUBIC CATHETER
Following some surgeries Long term situations Suprapubic catheter indwelling catheter directly inserted through an incision into the lower abdomen directly into the bladder Nursing: Keep area clean & dry

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TUMORS OF THE RENAL SYSTEM

Cancer of bladder most common cancer of urinary tract Twice as common in men Common age between 50-70 yo
Correlation between cigarette smoking/bladder cancer

Chemicals pass between via bloodstream to kidneys

During a routine assessment, a client tells you, Ive been noticing blood in my urine.What would be your appropriate nursing action?

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BLADDER CANCER

CANCER OF KIDNEY
Rare, but serious Most patients between 50-70 yo Risk factors:
Smoking Obesity HTN Years of hemodialysis Radiation exposure Asbestos Industrial pollution

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3 CLASSIC SYMPTOMS OF KIDNEY CANCER

Hematuria Flank pain dull Mass in area Other symptoms:
Weight loss Fever Anemia Fatigue Swelling in legs

RENAL CELL CANCER STAGING

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THERAPEUTIC MANAGEMENT
RADIATION THERAPY
SURGICAL INTERVENTION FOR BLADDER TUMORS
TUMOR RESECTION PARTIAL CYSTECTOMY

RADICAL CYSTECTOMY

URINARY DIVERSION

URINARY DIVERSION SURGERIES

Continent urinary diversion surgeries
Kock pouch reservoir created from segment of ileum Ileal conduit Indiana pouch reservoir is formed from colon and cecum and portion of the ileum is brought to the surface

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RENAL DISORDERS
Glomerulonephritis Polycystic kidney disease Acute renal failure End-stage renal disease Diabetic neprhopathy Nephrotic syndrome Nephrosclerosis

OBJECTIVES
Describe the KEY FACTORS associated with the development of renal disorders. Compare and contrast the pathophysiology, clinical manifestations, medical management, and nursing management for patients with renal problems. Describe the nursing management of patients with acute and chronic renal failure. Compare and contrast the renal replacement therapies including hemodialysis, peritoneal dialysis, and kidney transplantation.

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A group of kidney disease caused by inflammation of the capillary loops in the glomeruli of the kidney. Most often follows infections with group A beta-hemolytic streptococcus.

URTI, skin infection, autoimmune processes (SLE) predispose to glomerulonephritis

Symptoms appear 2 to 3 weeks after original infection. Has higher incidence in men than in women; may occur at any age

STREPTOCOCCAL INFECTION ANTIBODY FORMATION Antigen-antibody complex ACUTE INFLAMMATION AND DAMAGE
INCREASED CAPILLARY PERMEABILTY
Hematuria Albuminuria

GLOMERULUS SWELLING

CELL PROLIFERATION

CONGESTION-DECREASED GFR Oliguria and elevated serum urea

STIMULATION OF RENIN SECRETION

Elevated BP and edema

FULL RECOVERY

ACUTE RENAL FAILURE DEATH

CHRONIC GLOMERULONEPHRITIS CHRONIC RENAL FAILURE

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ASSESSMENT
Early symptoms may be mild: pharyngitis, fever, and

malaise

Recent URTI or skin infections, peridarditis, lower UTI Weakness and fatigue Anorexia, N/V Cocoa-colored urine Peripheral edema Hypertension

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Elderly clients with AGN have less noticeable symptoms. Proteinuria, malaise, nausea, and arthralgia are more likely to occur while hypertension and edema occur less often.

coffee-colored urine, smoky, cocoa-colored urine, teacolored urine due to CHON

and RBCs leaked into it.

Facial and periorbital edema occur edema initially and followed generalized edema colloid osmotic pressure of

the blood drops and sodium and water are retained

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HYPERTENSION increased renin secretion and decreased GFR

tissue swells and stretches the capsule

FLANK PAIN kidney

General signs of inflammation are present, including malaise, fatigue, headache, anorexia, and nausea. Urine output decreases (oliguria) as GFR declines

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DIAGNOSTIC & LABS

Hematuria, proteinuria (most

important indicator of glomerular injury),

hypoalbuminemia, crea & BUN

Streptococcal antibodies, antistreptolysin O (ASO), and exoenzyme antistreptokinase (ASK) are elevated
Na, K, Phosphate Creatinine clearance ESR Metabolic acidosis

THERAPEUTIC MANAGEMENT

PLASMAPHARESIS MEDICATIONS: Penicillin, antimicrobials, analgesics, vitamin and electrolyte replacements DIALYSIS if the disease progresses to renal failure

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NURSING MANAGEMENT
Enforce CBR, reverse isolation Monitor strictly VS, I&O, neurocheck, monitor for signs of hypocalcemia (increased phosphate) Meticulous skin care. Uremic frost assist in bathing pt Meds: Na HCO3 due Hyperkalemia Kayexelate enema Anti HPN Hydralazine (Apresoline) Vit & minerals (Multivitamins) Phosphate binders (Amphogel) Al OH gel - S/E constipation Decrease Ca Ca gluconate

What dietary instructions should be included in the teaching plan?

DIET FOR GLOMERULONEPHRITIS Protein restriction

High carbohydrates
Potassium restriction Sodium restriction

Fluid restriction (if oliguria is present

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Nephrotic Syndrome
Protein in urine >3.5g/per day May result from other disease processes Large amts. of protein lost in UA Serum albumin/total serum protein are decreased Fluids low/leaks into tissues, causing edema Low sodium diet/low protein diet/diuretics may be used/*daily wts/I & O

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THROMBOEMBOLI are common complication and may occlude peripheral veins and arteries, pulmonary arteries, and renal veins.

Severe generalized edema Symptoms of renal failure Loss of appetite and fatigue Amenorrhea

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THERAPEUTIC MANAGEMENT
Control edema
Na restricted diet Avoidance of Na-containing drugs Diuretics (Lasix) Salt-poor albumin

High-protein diet, high calorie Na diet Bed rest Monitor laboratory data Monitor for pulmonary edema MIO and fluid restriction Monitor for infection

Glucocorticoids (Prednisone) ACE inhibitors to reduce protein loss NSAIDS to reduce proteinuria Antimicrobials Antihypertensives Diuretics

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Diabetic Nephropathy
Most common renal failure Long term effects of diabetes Damage to small vessels in kidneys Risk factors include: hypertension, genetic predisposition, smoking, chronic hyperglycemia Progression to urine decrease, toxic waste build up leading to kidney failure

Hereditary disease characterized by cyst formation and massive kidney enlargement affecting both children and adults

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Autosomal dominant form affects adults

Affects males, females equally If you have the gene, you have the disease Every affected individual has an affected parent

Autosomal recessive form usually diagnosed in children

Either sex gets disease Siblings are usually affected, but not parents

Affected infants have changes in physical appearance that include epicanthal folds, pointed nose, small chin, and low-set ears. Unlike the infant, adults with polycystic kidney disease have a normal appearance.

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Nephrosclerosis
Thickening and hardening of the renal blood vessels Changes in kidney- result in decreased blood supply to the kidney-can eventually destroy kidney High pressure within kidney cause damage Treatment is to reduce HTN

Acute vs. Chronic Renal Failure

Acute (Reversible!)
Sudden/complete loss kidney function Cause: failure of renal circulation, tubular, or glomeruli dysfunction
Pre-renal: hypo-perfusion of kidney (shock, hemorrhage,etc.) Intra-renal: damaged renal tissue (infection, transfusion rxs, burns, drugs, etc.) Post-renal: an obstruction somewhere distal to kidneys: renal flow (ex. calculi, stricture, tumor etc.)

Chronic: ESRD (Irreversible) Progressive uremia devps = affects all body systems funct. Glomeruli = GFR, *urine creatinine clearance, but serum *creatinine & *BUN , Na+ H20 retention = edema, CHF, crackles, *K+ , *metabolic acidosis

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Acute vs. Chronic renal failure

Acute S/S :
may include: *anuria (less 50cc/day) *oliguria (*less than 400cc/day or *30mL/hour) * or a normal urine output!, however, the serum BUN and Creatinine will be elevated for all above! appear critically ill, lethargic, n/v/d Chronic (ESRD) Anemia (dec. *erythropoetin) Po4 & Ca+ imbalance S/S:
+ JVD, peri-orbital edema, dependent/pitting edema, crackles, SOB Ammonia odor breath, anorexia, n/v Skin=uremic frost, gray-bronze skin, dry flakey, itchy skin, muscle cramps ? Bone fx Neuro = weakness, fatigue, confusion, seizures (anuria = less than 50cc/day) or *(oliguria=less 400cc/day)

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Acute vs. Chronic renal failure

Acute
skin & mucous membranes dry from dehydration, breath odor (uremic fetor), h/a, muscle twitch, specific gravity urine, BUN/creatinine, * 24hour urine creatinine clearance, * K+* worry about cardiac dysrhythmias, tissue edema, uremic frost, metabolic acidosis, anemia, PO4/Ca+/and F&E imbalance.** negative nitrogen balance

Chronic or ESRD Management:

Dietary: renal diet, low Protein, Na+, K+, fluid restriction, higher fats & CHO=calories, I&O Antacids: correct Po4/Ca+ imbalance, aluminum or ca+ carbonate: give meals
Anti-hypertensives, Erythropoietin (Epogen) = anemia, to K+ levels = resin *Kayexelate = po or/enema = exchg Na+/K+ bowel = loose stool or *require dialysis to lower K+

Acute vs. Chronic renal failure

Acute
4-phases of acute: Initiation phase = starts w/insult and ends with oliguria Oliguric Phase = period where uremic s/s begin, urinary output < 400mL/day, Bun, Cr, K+, (FV Excess), hypernatremia ( Na+) Diuretic Phase = signals U.O. , lab values better, dehydrated, uremia gone, GFR better! (FV deficit) Recovery Phase = improved renal function last (3-12 mos)

Chronic (ESRD) Management is Dialysis either Hemodialysis, or Peritoneal dialysis Or possibly a kidney transplantation= must find a donor match/ must worry about grafttransplantation rejection!

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Acute vs. chronic renal failure

Acute
Management:
Strict I&O K+ = Kayexelate po/enema first; if not better must use dialysis Check wt. daily,dietary protein, K+ (40-60mEq/day), & Na+ (2 gm./day) diet, K+ foods; soda, bananas, citrus Correction of *acidosis & elev PO4 levels = sodium bicarb, and phosphate binding agents like antacids (Phos-lo, Amphogel, calcium
carbonate, aluminum based antacids) thus, Ca+

Chronic or ESRD
I&O, fluid restriction ex. 700-1000cc/24 hr, so break-it-up / shift 1-2 gm. of low Na+diet, low K+ diet, avoid salt substitutes for they contain K+ ! BAD for you Low protein diet, however eat proteins of high biological value such as dairy

Bedrest to BMR & catabolism, thus, K+ & nitrogen waste prod (BUN/Cr)

products, eggs, meat, fish in small portions only RBC, Hbg/Hct: Give Epogen or Procrit SQ to increase (*erythropoetin)

RENAL REPLACEMENT THERAPY Dialysis

To substitute kidney excretory functions during renal failure

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DIALYSIS
Used when the client develops clinical manifestations of fluid volume excess
hyperkalemia, BUN, creatinine, metabolic acidosis, or lifethreatening symptoms of uremia in extreme cases to remove drugs, toxins etc. from an accidental overdose

Often called the artificial kidney or dialyzer

removes water & toxic waste products or (nitrogenous wastes) from the blood stream

Types of Dialysis
1. Peritoneal

2. Hemodialysis

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Peritoneal Dialysis
Intermittent peritoneal dialysis=acute or chronic renal failure Continuous ambulatory peritoneal dialysis (CAPD) =chronic renal failure Continuous cycling peritoneal dialysis (CCPD) =prolonged dwelling time Indwelling catheter is implanted in the peritoneum A connecting tube is attached to the external end of peritoneal catheter T tube (tenckhoff, swan, cruz)

Peritoneal Dialysis
Plastic bag of dialysate solution is inserted to the other end of T tube the other end is recap Dialysate bag is raised to shoulder level and infused by gravity in the peritoneal cavity (infusion time=10 min/2 L) Dwelling time 20-45 min. (depending on doctors order)
WOF: RESPIRATORY STATUS

At the end of dwelling time dialysis fluid is drained from the peritoneal cavity by gravity (draining time-10-20 min/2 L) Then repeat the procedure when necessary

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Peritoneal Dialysis
NOTE: Dialysis solution must be room-warmed before use (warm solution helps dilate

Drugs (heparin, potassium and antibiotics) must be added in advance Allow the solution to remain in the peritoneal cavity for the prescribed time Check outflow (effluent) for cloudiness, blood and fibrin (early peritonitis) Never push the catheter in

peritoneal vessels, which increases urea clearance and to lessen abdominal cramping)

Peritoneal Dialysis
NOTE: Monitor vital signs regularly Keep a record of patients fluid balance (daily weighing) Monitor blood chemistry Turn the patient side to side if drainage stopped. Observe for abdominal pain (cold solution) dialysate leakage (prevent infection) Intake must be equal to output or a liitlehigher (200ml)

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SIESTA

Hemodialysis
A process of cleansing the blood (accumulated waste products) Patients access is prepared and cannulated (surgically) One needle is inserted to the artery (brachial) then blood flow is directed to dialyzer (dialysis machine) The machine is equipped with semi-permeable membrane surrounded with dialysis solution Waste products in the blood move to the dialysis solution passing through the membrane by means of diffusion Excess water is also removed from the blood by way of ultrafiltration The blood is then returned to the vein after it has been cleansed

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Hemodialysis
NOTE: Blood can be heparinized unless it is contraindicated (bleeding tendency) Dialysis solution has some electrolytes and acetate and HCO3 are added to achieve proper pH balance Methods of circulatory access
arteriovenous fistula arteriovenous graft or U tube (polytetrafluoroethylene)

arteriovenous graft or U tube

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Hemodialysis
NOTE: Assess the access site for bruit sounds (through auscultation) Absence of thrill=may indicate occlusion (through palpation) Assess neurovascular condition distal to the site No BP taking on the access site Cover the access site with adhesive bandage (dry sterile dressing) Dietary adjustments of protein, sodium, potassium and fluid intake Monitor vital signs regularly Check blood chemistry Constant monitoring of hemodynamic status, electrolytes and acid base balance Start low flow rate, watchout dialysis disequilibrium) 250 ml/hr (rate), 3-4 hours duration

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