Renal Nursing

Structure and Functions

The Urinary Tract KIDNEY Bean-shaped organ Highly vascular Has exocrine and endocrine functions Weight: 150 g Length: 4.5 inches (11.4 cm) Width: 2.5 inches (6.4 cm) Location: Retroperitoneal Supine: T12-L3 th th Trendelenburg: 10 -11 ICS Standing: Down the iliac crest 1 contains about million nephrons.

NEPHRON 2 sections: 1. Bowman's capsules - outer cortex region 2. Renal tubules - from the cortex into the darker medulla. Filtration: Blood flows to the glomerulus (from the renal artery)

Pressure in the glomerulus forces: water, glucose, urea, salts through the capillary wall and tubule (Protein & blood cells remain)

Blood leaves the glomerulus

Moves to capillaries that surround the renal tubule.

Glomerular filtrate passes along the tubule. (GFR 125 cc/min)

Glucose, most of the water and salts are absorbed back into the blood in the nearby capillaries. (TRR 124 cc/min)

Urea and other wastes stay dissolved in the glomerular filtrate.

They pass down the tubule and eventually reach the bladder. (Blood flows out of the kidney to the renal vein.)

URETERS Length: 10-12 inches (25-30 cm) Diameter: 2-8 mm Major function: Channel urine down to the bladder by peristaltic waves (1-5x/min) Ureterovesical valve prevents reflux of urine

URINARY BLADDER Hollow, spherical, muscular organ Anterior and inferior to the pelvic cavity Posterior to Symphysis Pubis Elastic as it stores urine a. First Urge: 200-300 cc b. Moderately full: 500-600 cc c. Maximum capacity: 1000-1800 cc (Rises up to the Symphysis Pubis) Effects of: a. Parasympathetic Nerves: Contract b. Sympathetic Nerves: Relax

URETHRA Anterior to the vagina (female) behind symphisis pubis Length a. Female: 3-5 cm b. Male: 20 cm

DIAGNOSTIC STUDIES
CYSTOSCOPY Provides a means of direct visualization of the urethra, bladder, and urethral orifices The Cystoscope (an instrument with lighted lens) is inserted into the urethra Biopsy specimens, lesions, small stones and small foreign bodies can be removed by this means. Preparation for Cystoscopy: Written consent Force fluids Done under local / general anesthesia Inform that desire to void will be felt Position: Lithotomy After Cystoscopy: BR until VS are stable Blood-tinged (pink) witihin 24-48 hours is normal Due to irritation: a. Dysuria b. Frequency c. Hematuria Assess for: a. Urinary retention b. Signs of infection c. Prolonged / excessive hematuria Monitor VS and I&O Force fluids

KUB (Abdominal x-ray film) KUB (Kidney, Ureters, Bladder) Used to determine the size, shape and position of the kidneys. Used to note any stones that may be present in the kidney, bladder or ureters Procedure for KUB A flat plate x-ray film is placed over the abdomen Non-invasive Assure patient it is painless Bowel preparation as feces / gas may interfere with the visualization

EXCRETORY UROGRAM / INTRAVENOUS PYELOGRAPHY An x-ray photograph of the renal pelvis and ureter. A radiopaque material is given IV and excreted through the kidneys making the radiographic visualization possible. Before IVP Secure written consent NPO 6-8 hours

Bowel preparation Check for hypersensitivity to iodine (sea foods) Emergency drug: Epinephrine (for possible anaphylactic shock) Inform: warm flushing sensation on IV injection site is normal

After the IVP . . . Monitor VS Increase fluid intake flush the dye Inform: Burning sensation during urination may be experienced Assess: Late allergic reactions RETROGRADE PYELOGRAM (RPG) Outlines renal pelvis and ureters by injecting a dye into each ureter with use of catheter through cystoscope Before RPG: Written consent Check for iodine / dye allergy Inform: discomfort of the procedure Emergency drug: Epinephrine (for possible anaphylactic shock) After RPG: Monitor VS Increase fluid intake flush the dye Inform: Burning sensation during urination may be experienced Assess: Late allergic reactions RENAL ARTERIOGRAM Provides x-ray pictures of the blood vessels supplying the kidney. Introduction of a radiopaque dye directly into the renal artery. Most common site is the femoral artery Used in evaluating persons suspected of having renal artery stenosis, abnormalities on the renal blood vessels or vascular damages. Before RA Cleanse bowel(Laxative) Shave catheter insertion site After RA VS until stable Cold puncture on the puncture site Check for swelling / edema Assess peripheral pulses Check for color and temperature of the skin Bedrest for 24 hours, no sitting Measure I and O

ULTRASOUND Detects tumors, cyst obstructions and abscesses Nursing Interventions: Cleanse the bowel Force fluids Withhold voiding RENAL BIOPSY To determine malignancies Nursing Interventions NPO 6-8 hours Check PTT, PT (Bleeding is usual) Mild Sedation Local anesthesia Hold breath during insertion of needle UTZ to locate kidneys Care after biopsy Bedrest 24 hours Monitor V/S Assess for pain, N/V HCT and HGB to detect bleeding No heavy activity 2 weeks Key Signs and Symptoms of Renal Problems EDEMA - associated with fluid retention - renal dysfunctions usually produce ANASARCA PAIN Suprapubic pain= bladder Colicky pain on the flank= kidney HEMATURIA Painless hematuria may indicate URINARY CANCER! Early-stream hematuria - urethral lesion Late-stream hematuria - bladder lesion DYSURIA - Pain with urination - lower UTI POLYURIA - More than 2 Liters urine per day OLIGURIA - Less than 400 mL per day ANURIA - Less than 50 mL per day

ALTERATIONS IN THE URINARY SYSTEM

Acute Renal Failure Sudden interruption of kidney function to regulate fluid and electrolyte balance and remove toxic products from the body A reversible condition characterized by a sudden reduction or cessation of renal function retention of waste compounds increase in urea and creatinine The Three Phases of Acute Renal Failure 1. Oliguric phase Urine output less than 400 cc/24 hours duration 12 weeks Manifested by dilutional hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia, and metabolic acidosis Diagnostic tests: BUN and creatinine elevated 2. Diuretic phase Diuresis may occur (output 35 liters/day) due to partially regenerated tubules inability to concentrate urine Duration: 23 weeks; manifested by hyponatremia, hypokalemia, and hypovolemia Diagnostic tests: BUN and creatinine slightly elevated 3. Recovery or convalescent phase Renal function stabilizes with gradual improvement over next 312 months Laboratory findings: Urinalysis: Urine osmo and sodium BUN and creatinine levels increased Hyperkalemia Anemia ABG: metabolic acidosis Nursing interventions Monitor fluid and Electrolyte Balance Reduce metabolic rate Promote pulmonary function Prevent infection Provide skin care Provide emotional support Nursing interventions 1. Monitor and maintain fluid and electrolyte balance. a. Measure l & O every hour. note excessive losses in diuretic phase b. Administer IV fluids and electrolyte supplements as ordered. c. Weigh daily and report gains. d. Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as needed 2. Monitor alteration in fluid volume. a. Monitor vital signs, PAP, PCWP, CVP as needed. b. Weigh client daily. c. Maintain strict I & O records. 3. Assess every hour for hypervolemia a. Maintain adequate ventilation.

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b. Restrict FLUID intake c. Administer diuretics and antihypertensives Promote optimal nutritional status. a. Weigh daily. b. Administer TPN as ordered. c. With enteral feedings, check for residual and notify physician if residual volume increases. d. Restrict protein intake to 1 g/kg/day e. Restrict POTASSIUM intake d. HIGH CARBOHYDRATE DIET, calcium supplements Prevent complications from impaired mobility (pulmonary embolism, skin breakdown, and atelectasis) Prevent fever/infection. a. Assess for signs of infection. b. Use strict aseptic technique for wound and catheter care. Support client/significant others and reduce/ relieve anxiety. a. Explain pathophysiology and relationship to symptoms. b. Explain all procedures and answer all questions in easy-to-understand terms c. Refer to counseling services as needed Provide care for the client receiving dialysis. Provide client teaching and discharge planning concerning a. Adherence to prescribed dietary regimen b. Signs and symptoms of recurrent renal disease c. Importance of planned rest periods d. Use of prescribed drugs only e. Signs and symptoms of UTI or respiratory infection need to report to physician immediately

Chronic Renal Failure Gradual, Progressive irreversible destruction of the kidneys causing severe renal dysfunction. The result is azotemia to UREMIA Is an irreversible condition of progressive damage to the nephrons and glomeruli retention of waste compounds increase urea and creatinine Prerenal CAUSE: Factors interfering with perfusion and resulting in diminished blood flow and glomerular filtrate, ischemia, and oliguria; include CHF, cardiogenic shock, acute vasoconstriction, hemorrhage, burns, septicemia, hypotension, anaphylaxis Intrarenal CAUSE: Conditions that cause damage to the nephrons; include acute tubular necrosis (ATN), endocarditis, diabetes mellitus, malignant hypertension, acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray dyes, pesticides, anesthetics)

Postrenal CAUSE: Mechanical obstruction anywhere from the tubules to the urethra; includes calculi, BPH, tumors, strictures, blood clots, trauma, and anatomic malformation

First stage (Diminished Renal reserve) Renal function is reduced No metabolic wastes accumulate. The healthier kidney compensates for the diseased one. Asymptomatic Second stage (Renal Insufficiency) Metabolic wastes accumulate Decreasing GFR, classified as mild, moderate, or severe. (25% nephrons are damaged) symptoms of renal failure (increasing BUN, fatigue) Final stage (End-stage Renal failure) Excessive amounts of metabolic wastes, Kidneys are unable to maintain homeostasis - a life-threatening condition. Assessment findings 1. Nausea, vomiting; diarrhea or constipation; decreased urinary output 2. Dyspnea 3. Stomatitis 4. Hypertension (later), lethargy, convulsions, memory impairment, pericardial friction rub Diagnostic tests: a. 24 hour creatinine clearance urinalysis b. Protein, sodium, BUN, Crea and WBC elevated c. Specific gravity, platelets, and calcium decreased D. CBC= anemia Medical management 1. Diet restrictions 2. Multivitamins 3. Hematinics and erythropoietin 4. Aluminum hydroxide gels 5. Anti-hypertensive 6. Anti-seizures 7. DIALYSIS Nursing interventions 1. Prevent neurological complications. a. Assess every hour for signs of uremia (fatigue, loss of appetite, decreased urine output, apathy, confusion, elevated blood pressure, edema of face and feet, itchy skin, restlessness, seizures). b. Assess for changes in mental functioning. c. Orient confused client to time, place, date, and persons; institute safety measures to protect client from falling out of bed. d. Monitor serum electrolytes, BUN, and creatinine as ordered 2. Promote optimal GI function.

a. Assess/provide care for stomatitis b. Monitor nausea, vomiting, anorexia c. Administer antiemetics as ordered. 3. 4. 5. Monitor/prevent alteration in fluid and electrolyte balance Assess for hyperphosphatemia (paresthesias, muscle cramps, seizures, abnormal reflexes), and administer aluminum hydroxide gels (Amphojel) as ordered Promote maintenance of skin integrity. a. Assess/provide care for pruritus. b. Assess for uremic frost (urea crystallization on the skin) and bathe in plain water Monitor for bleeding complications, prevent injury to client. a. Monitor Hgb, hct, platelets, RBC. b. Hematest all secretions. c. Administer hematinics as ordered. d. Avoid lM injections Promote/maintain maximal cardiovascular function. a. Monitor blood pressure and report significant changes. b. Auscultate for pericardial friction rub. c. Perform circulation checks routinely. Promote/maintain maximal cardiovascular function. a. Administer diuretics as ordered and monitor output. b. Modify drug doses Provide care for client receiving dialysis.

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DIALYSIS a procedure that is used to remove fluid and uremic wastes from the body when the kidneys cannot function Two methods 1. Hemodialysis 2. Peritoneal dialysis Hemodialysis Alternates to the excretory but not on the endocrine function of the kidneys Practice ARM PRECAUTION Assess for patency: auscultate for bruit, palpate for thrill Tourniquet be always available if A V shunts is present. A V fistula may be used after 4-6 weeks wait for healing. It can be used for 3-4 years. Vascular access: Arteriovenous fistula. Arteriovenous graft. External arteriovenous shunt. Femoral vein catheterization. Subclavian vein catheterization.

A V shunt may be used immediately

Nursing Interventions in Hemodialysis: 1. Facilitating fluid in electrolyte balance. Preventing hypovolemia and shock. Administer blood transfusion as ordered Omit dose of hypertensive drug Preventing disequilibrium phenomenon. Initial hemodialysis done for 30 mins. only Disequilibrium syndrome is caused by more rapid removal of waste products from blood brain barrier, cerebral edema causes signs and symptoms of increased ICP, e.g. restlessness, headache, dizziness, nausea and vomiting, hypertension, etc. Preventing blood loss. Promoting comfort Maintaining activity and nutrition Facilitate learning.

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Peritoneal Dialysis Advantages: Steady state of blood chemistries. Patient can dialyze alone in any location without need for machinery. Patient can readily be taught the process. Patient has few dietary restrictions; because of loss of CHON in daily dialysate, the patient is usually placed on a high CHON diet. Patient has much more control over daily life. Peritoneal dialysis can be used for patients that are hemodynamically unstable. Care during Peritoneal Dialysis: Regulating fluid volume and drainage Promoting comfort. Preventing complications. a. Monitor urine / blood glucose levels Teaching Plan a. The process of dialysis and how the dialysis relates to the patients own body needs. b. Signs and symptoms of infection (peritonitis) c. Appropriate care of the permanent peritoneal catheter. Common side effects of treatment, means of controlling mild symptoms. Changes in medication schedule required before and after dialysis. Activity schedule as physical capabilities permit, with animal inference from scheduled dialysis time.

URINARY TRACT INFECTION Infections of the kidney (pyelonephritis), bladder (cystitis) and urethra (urethritis). Classified as upper (kidney) or lower (bladder, urethra). a. Etiology Bacteria, usually E. Coli.

Pyelonephritis spread of bacteria into the bloodstream, urinary reflux, obstruction or ascending UTI. Cystitis: a. BPH b. Occurs more commonly in women c. Uretheritis - bacterial and viral infections Other factors include: a. Stasis b. Urinary retention and bladder distention. c. Instrumentation d. Poor hygiene e. Fecal incontinence f. Sexual transmission of bacteria Assessment findings 1. Low-grade fever 2. Abdominal pain 3. Enuresis 4. Pain/burning on urination 5. Urinary frequency 6. Hematuria

Assessment findings: Upper UTI 1. Fever and CHIILS 2. Flank pain 3. Costovertebral angle tenderness Laboratory Examination 1. Urinalysis 2. Urine Culture Nursing interventions 1. Administer antibiotics as ordered. 2. Provide warm baths and allow client to void in water to alleviate painful voiding. 3. Force fluids. Nurses may give 3 liters of fluid per day. 4. Encourage measures to acidify urine (cranberry juice, acid-ash diet). Nephrolithiasis/Urolithiasis Predisposing factors 1. Diet: large amounts of calcium and oxalate 2. Increased uric acid levels 3. Sedentary life-style, immobility 4. Family history of gout or calculi 5. Hyperparathyroidism

Pathophysiology Supersaturation of crystals due to stasis Stone formation May pass through the urinary tract

OBSTRUCTION, INFECTION and HYDRONEPHROSIS Assessment findings 1. Abdominal or flank pain 2. Renal colic radiating to the groin 3. Hematuria 4. Cool, moist skin 5. Nausea and vomiting Diagnostic tests 1. KUB Ultrasound and X-ray: pinpoints location, number, and size of stones 2. IVP: identifies site of obstruction and presence of non-radiopaque stones 3. Urinalysis: indicates presence of bacteria, increased protein, increased WBC and RBC (hematuria) Medical management 1. Surgery a. Percutaneous nephrostomy: tube is inserted through skin and underlying tissues into renal pelvis to remove calculi. b. Percutaneous nephrostolithotomy: delivers ultrasound waves through a probe placed on the calculus. 2. Extracorporeal shock-wave lithotripsy: delivers shock waves from outside the body to the stone, causing pulverization a. Pain management : Morphine or Meperidine b. Diet modification Nursing interventions 1. Strain all urine through gauze to detect stones and crush all clots. 2. Force fluids (30004000 cc/day). 3. Encourage ambulation to prevent stasis. 4. Relieve pain by administration of analgesics as ordered and application of moist heat to flank area. 5. Monitor intake and output 6. Provide modified diet, depending upon stone consistency: Calcium, Oxalate and Uric acid stones

Calcium stones - limit milk/dairy products; provide acid-ash diet to acidify urine (cranberry or prune juice, meat, eggs, poultry, fish, grapes, and whole grains) Oxalate stones - avoid excess intake of foods/ fluids high in oxalate (tea, chocolate, rhubarb, spinach); maintain alkaline-ash diet to alkalinize urine (milk; vegetables; fruits except prunes, cranberries, and plums)

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Uric acid stones - educe foods high in purine (liver, beans, kidneys, venison, shellfish, meat soups, gravies, legumes); maintain alkaline urine Administer allopurinol (Zyloprim) as ordered, to decrease uric acid production. Provide client teaching and discharge planning concerning: Prevention of Urinary stasis by maintaining increased fluid intake especially in hot weather and during illness; mobility; voiding whenever the urge is felt and at least twice during the night Adherence to prescribed diet Need for routine urinalysis (at least every 34 months) Need to recognize and report signs/ symptoms of recurrence (hematuria, flank pain).

BLADDER CANCER More common in males Cause: unknown g. Risks Factors Exposure to cigarette smoke Pelvic radiation Use of cyclophosphamide Chronic cystitis Bladder calculi Schistosomiasis h. Assessment Painless hematuria (first sign) Dysuria Gross hematuria Obstruction to urine flow Development of fistula (urine from the vagina, fecal material in the urine) Collaborative Management Chemotherapy Thiotepa Mitomycin C Doxorubicin (Adriamycin) Cyclophosphamide (cytoxan)

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Cisplatin (Platinol) Methotrexate Radiation Surgery - Urinary Diversion Surgeries

Types of Urinary Diversion: a. Ileal Conduit For CA Bladder Adult Neurogenic Bladder Insterstitial Cystitis Irreparable Trauma

Important! External collection device needed Proper fitting to prevent urine leak to the skin Skin care with warm water and mild soap Complications: Obstruction to the urine flow via small intestines secondary to edema Infection Stoma prolapse Calculi Electrolyte imbalances b. Ureterostomy Either or both ureters are out to the abdominal wall Ureteral stoma is created External collection device is needed Infection is a potential hazard Increase fluid intake c. Nephrostomy To drain the urine while ureteral inflammation from trauma or calculus is present

Complications: Infection (Pyelonephritis) Blockage of the catheter Important! DO NOT IRRIGATE!!! d. Ureterosigmoidostomy No external collection device Passage of flatus includes leak of urine Infection is possible

BENIGN PROSTATIC HYPERPLASIA - Enlargement of the prostate that causes outflow obstruction - Common in men older than 50 years old Assessment findings 1. DRE: enlarged prostate gland that is rubbery, large and NON-tender 2. Increased frequency, urgency and hesitancy 3. Nocturia, DECREASE IN THE VOLUME AND FORCE OF URINE STREAM Medical management 1. Immediate catheterization 2. Prostatectomy 3. TRANSURETHRAL RESECTION of the PROSTATE (TURP) 4. Pharmacology: alpha-blockers, alpha-reductase inhibitors. SAW palmetto Nursing Intervention 1. Encourage fluids up to 2 liters per day 2. Insert catheter for urinary drainage 3. Administer medications alpha adrenergic blockers and finasteride 4. Avoid anticholinergics 5. Prepare for surgery or TURP 6. Teach the patient perineal muscle exercises. Avoid valsalva until healing Nursing Intervention: TURP 1. Maintain the three way bladder irrigation to prevent hemorrhage 2. Only initially the drainage is pink-tinged and never reddish 3. Administer anti-spasmodic to prevent bladder spasms PROSTATE CANCER - a slow growing malignancy of the prostate gland - Usually an adenocarcinoma - This usualy spread via blood stream to the vertebrae Predisposing factor Age Assessment Findings 1. DRE: hard, pea-sized nodules on the anterior rectum 2. Hematuria 3. Urinary obstruction 4. Pain on the perineum radiating to the leg Diagnostic tests 1. Prostatic specific antigen (PSA) 2. Elevated SERUM ACID PHOSPHATASE indicates SPREAD or Metastasis Medical and surgical management 1. Prostatectomy 2. TURP 3. Chemotherapy: hormonal therapy to slow the rate of tumor growth 4. Radiation therapy

Nursing Interventions 1. Prepare patient for chemotherapy 2. Prepare for surgery Nursing Interventions: Post-prostatectomy 1. Maintain continuous bladder irrigation. Note that drainage is pink tinged w/in 24 hours 2. Monitor urine for the presence of blood clots and hemorrhage 3. Ambulate the patient as soon as urine begins to clear in color