410 Lectures

-          Over 2 millions nephrons; As we age the cortical nephrons are

nonfunctionals and so we lose nephrons.

-          ***KNOW THE PARTS OF A NEPHRON;  The start is Bowman’s capsule

and that makes up the glomerulus (beginning stages of urine formed there-

filtration) this network of capillaries have a semipermeable membrane (in a

normal environment the membrane don’t allow protein), filtrate results from

filtration; filtrate is like serum w/ the exception of protein (watery clear part

of blood without RBC);

-           Strept throat (the bacteria can cause a antibody response in the

glomerulus), Hypertension, UTI & Diabetes (damage membrane) sometimes

causes protein to get into the filtrate, once its in the filtrate it is lost in urine

and no longer in the body; (Pregnant women with proteinurea will have  a

decrease amt of serum protein) All these things can damage the glomerulus

and Bowman’s capsule;

-          What is the consequence of having low serum protein?  Delivery of

medication, muscle and cell problems, slow healing, **Risk for delayed

healing rt to low serum protein from proteinurea;

Now Check for edema esp. in face w/ these patients (water was leaving the

cells, protein holds water in the intravascular compartment) Also, skin

integrity rt fluid in interstitial space;  capillary refill will be sluggish, skin color

pale b/c less blood supply, mental status altered; Water is all in the intestinal

space, intravascular vol deficit w/ interstitial volume excess- fluid is in wrong

space all b/c protein is gone;

▪  Give this pt a hypertonic soln or give pt shot of protein (albumin);  If it

works pt will have stronger pulse and bp and urine will increase, less

edema, better capillary refill

-          Second part of nephron is PCT – proximal convulted tubule,  (120 mL

per min forming filtrate) 90% of what is filtered is reabsorbed, surrounding

the PCT is an arteriole and the products move back into the blood; 90% of

whats filtered is reabsorbed;

▪ If the PCT is broken the urine volume will INCREASE!  The volume in our

body will be low… decrease pulse, bp, cold clammy skin, etc.  If

potassium cant be reabsorbed it will be low in the serum along with

other electrolytes

-          The third is the Loop of Henle it concentrates urine (Loop Diuretics

work here and block the reabsorption of sodium, which water follows); 

-          The DCT is next, Distal convulated tubule, the primary role is

secretion; vesicles around DCT pick up any extra concentrated electrolytes

back into the nephron after they were reabsorbed; 

▪ ADH has its effect on the DCT, water is reabsorbed and not secreted into

the urine; 

-          The fifth part is the collecting duct, it transfers the filtrate to the

renal pelvis. FINAL part of the tube and now the filtrate is called URINE;

-          Urine then flows down the ureters to the bladder into the uretha to

EXCRET so the collecting ducts are for excretion;

-          Question: Which pt is more likely to experience renal compromise

(decreased urine production)? 

▪ A pt w/ blood pressure of 92/45 for 12 hr

▪ A pt w/ white blood cell count of 12,000 (5-10,000 – normal)

▪ A pt w/ 5 yr hx of DM

▪ A pt w/ hx of myocardial infection

-          The ANSWER is A b/c this blood pressure has a mean arterial pressure

(MAP[KE1] ) of 62 mm hg. The kidney has a difficult time regulating GFR w/ a

MAP less then 65 mm Hg; If this was my pt from ER  what would we see if

fluid vol overload, increased resp rate, nasal flaring, HOB elevated, pulse

oximeter, crackles in lung sound or rales, so primary for this pt would be

pulmonary; Next Cardiac mayb distended neck veins, puffy & edema, could

have pounding pulse w/ increased rate,  will hear S3 (APEX is where this will

be heard)

-          Filtration must have adequate blood flow and pressure, when pressure

falls vol of filtrate decreases and vol of urine decreases which can cause fluid

overload b/c all of it is retained.  Prolonged hypotension can cause fluid

overload. Failure to filter is retention in the body, so electrolytes will go up,

like Potassium (meaning Cardiac should be evaluated when something is

wrong with filtration)

Bicarbonate Reabsorption

▪ •      Secretion of hydrogen ions

▪ •      Secretion of nonvolatile [acids that do not form a gas] acids

(phosphate, ammonia, urea, etc)

STORY - COPD pt have CO2 trapped and our levels increased which leads to

elevated carbonic acid; If this pt had healthy kidney it would recompensate

for it by holding onto bicarbonate and secrete other acids like ammonia but

when we have renal problems the kidney can’t do this and if it cant do that

the bicarb goes in the urine and the body has a low bicarb level This pt will

get bicarb tablets w/ pt having high resp rate b/c lungs tries to get rid of it;

** IF this was Pt is in fluid vol excess & have fluid in alveoli (resp rate goes

up);  This pt will be sicker b/c they cant blow off the CO2;  ( This pt would be

at risk for pneumonia, if a pt came in with or at risk for other respiratory

problems on top of renal problems & COPD they would be closer to nurse

station bc they are so prone to getting acidosis) 

Make and reabsorb bicarb and secrete others like ammonia. 

Renal Failure → Metabolic Acidosis

Regulation of Blood Pressure

▪ •      Production of Renin – regulates blood pressure

▪ Renin is produced when there is a decrease in blood pressure into the

kidney;

▪ •      Structures within the DCT (macula densa cells – lie beside

renin producing cells) sense decrease perfusion/pressure --

release renin -- renin converts angiotensinogen (from liver)

into Angiotensin I which converts (in lung) into Angiotensin II

(increases afterload & stimulates release of Aldosterone (from

adrenal) to enhance sodium reabsorption (pg 202)

▪ •      Renal Failure -> often hypertension

▪ CHF has less CO and less blood flow to kidney, with Renin in these people

the vessel are constricted which causes it to have even more decrease

in the CO, this is when we start meds like lisinopril (ACE INHIBITOR)

they block angiotension I to angiotension II which ultimately causes

less constriction.  People who come in after accidents taking this med

is the most important.

▪ Aldactone – Potassium sparing diuretic; if you give this you are blocking

Aldosterone which is blocking sodium reabsorption meaning Sodium is

going to be urinated out & Potassium is reabsorbed; what should they

drink with aldactone? Water, OJ, apple, pineapple?  Apple juice,

cranberry juice, water  (NO TROPICAL JUICES b/c they are high in

potassium)

Red Blood Cell Synthesis

▪ Produces erythropoietin: when oxygen delivery to kidney

decreased, erythropoietin is released which stimulates the

bone marrow to release RBCs into the circulation

▪ Renal failure → chronic anemia

The renal failure pt will have problem making this and will exhibit anemia

hemoglobin less than 12;  these pt have low oxygen;  How would you

evaluate a Hemoglobin of 8 (perform ADL w/out shortness of breath, absence

of heart pain & arrhythmias, Confusion due to not enough blood to brain,

seizure)

Epogen, Procrit – if these are effective hemoglobin level goes up, no

confusion, etc. 

Place these pt close to nursing station bc of low oxygen delivery to body due

to anemia!! Angina or arrhythmias from low o2 to heart; rest b/t activities;

diminished oxygen to body results in fatigue, SOB when carrying activities;

QUESTION:  A pt with renal failure is complaining of dyspnea.  The pt pulse

ox reading is 96% on room air.  However, the pt is visibly distressed with a

respiratory rate of 32 breaths/min.  A priority intervention would be:

A)     Elevate HOB 90 degrees

B)      Notify the respiratory therapist

C)      Administer a resp nebulizing treatment

D)     Administer Oxygen by NC

Answer: D high oxygen sat is an anemic pt that is showing signs of resp

distress may still be hypoxemic.  Thus administering oxygen is necessary. 

Conversion of Vitamin D (necessary for Ca++ absorption)

Ultraviolet light converts 7-dehydrocholesterol in skin to

cholecalciferol Kidney (& liver) hydroxylates this vitamin D into an

activated form

-          Active Vit D is necessary for Ca absorption in the small intestine

-          Renal Failure -> Low serum Calcium; Decrease in bone mass

(osteoporosis) due to PTH acting on bones to extract calcium out of bones.

These pt will take Vit D and calcium tablets; Calcium is best absorbed w/

food; 

-          Teach pt about bone breakage, fall precautions; (take away rugs,

extension cords, get safety in bathroom, lighting, etc) FALL RISK PT; use pull

sheet vs. pulling on arms; heart muscle may have problems if low serum

calcium;  weak again risk for falls, peristalsis activity down and may get

constipation ALL B/C VIT D!!!  Coagulation, delayed so they bleed easy; TUMS

is the cheapest source of Ca but must give with food, also antacid for acid

reflux drugs so take this on an empty stomach;  Ca and P oppositely related,

Administer drug called PHOS-LOW when the Ca is low so this inhibits

Phosphorus absorption, Corn & Milk is high in Phosphorus, they can take the

phos-low so the phosphorus is inhibited so now they will just reabsorb Ca;

Basal-gal another phosphorus binding agent, block it from absorbing;   

Tubules: Filtration, Reabsorption, Secretion, Excretion &

Regulation of Electrolytes

Glomerulus – Filtration

Proximal Tutble- reabsorption

Loop of Henele – concentration of urine

Distal tubule- secrete

Collecting Duct – excrete

▪ Calcium 9.0-10.5 mg/dl

▪ •      Decrease in serum calcium stimulates secretion of PTH to

increase reabsorption of calcium & excretion of phosphate;

mobilization of calcium from bone

▪ •      ¯ Ca+ level from Vitamin D in Renal Fail.

▪ •      A ¯ Ca+ level can also occur from: 1) Corticosteroids (¯ Ca+

absorption),  2) Diuretics Ca+ excretion, 3) diet

Signs and Symptoms of altered calcium levels

Consequences of altered calcium levels

Regulation of Electrolytes

▪ •      Sodium – the major extracellular cation (norm =135-145

mEq/l)

▪ •      Sodium reabsorption increases

l Decreased GFR, Aldosterone secretion, action of Atrial natriuretic

peptide

▪ •      Sodium reabsorption decreases

l Increased GFR & excess ECF volume

l Secretion of ADH

l Loop-affecting diuretics

▪ •      Potassium (norm = 3.5 - 5.5 mEq/L)

▪ •      Major intracellular cation

▪ •      Factors enhancing potassium excretion

l Increase in cellular potassium

l Metabolic/respiratory alkalosis

l High urine flow rates

l Aldosterone

l Loop Diuretics

Other Electrolytes of Concern

▪ •      Phosphate

▪ •      Magnesium

▪ •      Need to know Signs and symptoms of electrolyte alterations,

consequences of electrolyte alterations, foods high/low in

these electrolytes; nursing implications

Changes in Kidneys Associated with Aging

▪ •      Reduced renal blood flow causing kidney loss of cortical tissue

by 80 years of age

▪ •      Thickened glomerular and tubular basement membranes,

reducing filtrating ability

▪ •      Decreased tubule length with decreased glomerular filtration

rate

▪ •      Nocturnal polyuria and risk for dehydration (volume deficit)

Collecting duct is first to go and there is an inability to concentrate urine,

NOCTURIA, polyuria, sleep deprivation, slower thinking, emotional instability,

memory is altered;

-         Consequences of changes:

Reduced ability to filter

Reduced ability to excrete waste products

Nephrons more vulnerable to damage from low or high BP/& or DM

Assessment Techniques

▪ •      Family history and genetic risk assessment – DM, HTN,

Polycystic kidney disease

▪ •      Demographic data and personal history- where you work,

chemicals that’s nephrotoxic, Fast food,

▪ •      Diet history- High sodium intake from so much fast food; diets

high in protein trying to lose wt,

▪ •      Socioeconomic status

▪ •      Current health problems: DM HTN, etc. Meds toxic to kidneys

nonsteriodal anti-inflammatory (ibuprofen, Advil, Motrin,

Aspirin, all the general aches and pain w/ exception of Tylenol)

most arthritis drugs, ace inhibitors, loop diuretics, antibiotics

(REALLY NEPHROTOXIC),

Question:  A pt with hx of renal disease is admitted with acute shoulder

pain. Which order should the nurse question?

1.Pan cultures for temp >38.5 c

2.Metoprolol (beta blocker) 50mg by mouth BID

3.Ibuprofen 600mg by mouth every 8 hr as needed for pain: nurse could

suggest Tylenol

4.Digoxin 0.125 mg daily

Answer C: these are nephrotoxic and should not be given to a renal patient

Physical Assessment

▪ •      Inspection- discoloration (greater risk for bruising), edema,

color (pallor- look at mucous membranes), uremia (yellow skin

color)

▪ •      Auscultation – lungs crackles, S3 in heart, listen for renal bruit

abnormal blood flow b/c renal artery stenosis esp. HTN pt (high

sound so listen with diaphragm on midclavicular line around

belly button);

▪ •      Palpation- kidneys can be palpable but its advanced practice;

▪ •      Percussion- check for inflammation of kidney, rule out CVA

tenderness;

▪ •      Assessment of the urethra – visual, look for blood, mucus or

pus

-          BODY WT for fluid balance!!!!!

Urinalysis

▪ •      Color, odor, and turbidity – can be very dilute or concentrated

▪ •      Specific gravity varies w/ hydration

▪ •      pH

▪ •      Glucose **

▪ •      Ketone bodies **

▪ •      Protein ** (look at glomerulus)

▪ •      Leukoesterase ** (UTI)

Nitrates** UTI

▪ •      Cells, casts, crystals, and bacteria ** (don’t worry about these

as much)

Normal urine shouldn’t have the ***

-          WBC 18,000 orders urine for Culture: Clean Catch urine sample: clean

front to back, void, catch; from Foley, clamp for while to build up urine,

cleanse port, attach syringe to aspirate urine.

-          24 Hour urine is a direct reflection of glomeruler filtration;

Blood Tests

▪ •      Serum creatinine – Renal is only thing that would make this

high;

▪ o   Normal value is 0.8-1.5;

▪ §  # is as important as trend, normal it should stay same, if it

alters then something is wrong in kidneys

▪ •      Blood urea nitrogen- Tells about protein metabolism: Renal,

hydration, GI, dietary protein intake

▪ o   State of hydration affects BUN; (Dehydration can elevate BUN)

▪ o    May indicate GI bleeding (Elevate BUN)

▪ •      Ratio of blood urea nitrogen to serum creatinine ~ 10:1

-GFR Rate: Greater than 65 normal.  Should be around 120;

- 24 hours for creatinine clearance: How many mL of blood should have

creatinine filtered off; it should be 120 mL; get big 3L jug with preservative so

the metabolic activity stops when you put uine in there so put it on ice; tell pt

to empty bladder (if they cant go make sure they tell you next time) If she

empties at 10 don’t collect that first sample but start then and collect all

urine after emptying collected;  You must start over if for some reason you

miss one void, or if there is contamination of sample (poop); If not in hospital

keep ice in cooler, use Foleys only if absolutely necessary;

- 24 hr direct reflection of GFR: if normal is 120 but report is 40, GF is

impaired. This tells you they have 30% fx left, if they cant filter serum levels

of electrolytes and things go up & Substances stay in blood (K+ cardiac

problems) 

- If filtration is significantly impaired, meds will stay in body; STORY: dr.

orders digoxin (increase contractility ad CO, before hand ou must check HR

b/c this slows HR… used for tachycardia and atrial arrhythmia… visal defects

(halos) indicate dig tox, seeing yellow lights, N/V) If creatinine clearance is

30mL/min tell dr he may want to decrease dose bc this is high value (not

filtering well)

Other Urine Tests

▪ •      Creatinine clearance—best indication of overall kidney

function norm ~ 120 ml/min

l Nursing Implications 24 hr urine (described above), bucket and ice

▪ •      Urine electrolytes – Usually nephrologist consulted bc they

aren’t making enough urine

▪ •      Urine drug screens – observe pt void then you directly take to

lab (chain of command)

▪ •      Serum Osmolarity - Urine and plasma ( plasma norm ~290) &

urine osmolarity 

Have pt empty bladder,  start at that time and go to the other 24hr container;

If filtration is reduced to 30% of normal; Substances are staying in the blood..

medications will stay in body, etc.  Digoxin – check hr, it increases

contractiility and output;  Give digoxin to control a irregular rhythm;  (Digoxin

toxic – see visual halos, n/v, yellow lights); 

Question: What to do first, Laxic or collect sample of urine?  Sample of urine

b/c a lasix increases urine output by blocking reabsorption of sodium;

Urine Culture

Front back cleaning, etc. look over clean catch; remember to stop the

drainage (DON’T GET SAMPLE FROM BAG) clamp Foley to build it up then take

it from the port after CLEANSING;

Other Diagnostic Tests

▪ •      Bedside sonography/bladder scanners – want to know how

much urine is in bladder; looking for post void residual usually;

not invasive or painful;

▪ •      Computed tomography (CT scan) – doesn’t matter if fecal is

there b/c it slices and can get the picture.  VERY SHORT, 5-10

min.  Looks like a doughnut table that goes through the hole,

(hold your breath now breathe) usually they need to inject

contrast dye (dye is nephrotoxic- ask if they are allergic to

iodine or shellfish (shrimp lobsters, etc), if the pt was allergic

then the Dr. would order a antihistamine and a steroid and

epinephrine should be on hand just in case things got out of

hand. Metformin + contrast dye = renal failure, so STOP the

metformin 48hr before and after the test, make sure you get

some other diabetic med like insulin; Muco-Mist given orally

48hr before and after contrast medium may protect kidneys,

this med is also a mucolytic which loosens pulmonary

secretions and is the antidote for acetaminophen;

▪ •      Kidney, ureter, and bladder x-rays (KUB) (come in to ER

abdominal x-ray must have bowel preparation to be helpful)

▪ •      Renal Ultrasound – noninvasive, quick, painless, need fluids so

NPO isn’t necessary,  looks at the structures, NO DYE!

▪ •      Intravenous pyelography (IVP) iv injection of contrast medium

but with x-ray no CT; If bowel is full same as KUB must do NPO,

bowel prep, allergy, nephrotoxicity;

l Bowel preparation

l Allergy information

l Fluids

 

Urodynamic Studies

▪ •      Studies that examine the process of voiding include:

l Cystometrography – how strong is urinary stream

l Urethral pressure profile

l Electromyography

l Urine stream test

Cystography and Cystourethrography-

Instilling dye into bladder via urethral catheter

▪ •      Monitoring for infection

▪ •      Encouraging fluid intake

▪ •      Monitoring for changes in urine output and for development

of infection from catheter placement

Retrograde Procedures

▪ •      Retrograde procedures go against the normal flow of urine.

▪ •      Procedure identifies obstruction or structural abnormalities

with the instillation of dye into lower urinary tract.

▪ •      Monitor for infection. High risk than normal;

▪ •      Follow-up care is the same as for a cystoscopic examination.

Dye not absorbed it’s a topical, not nephrotoxic;

Cystoscopy/Cystourethroscopy=“Cysto” see all way up ureters

l Procedure is invasive.

l Consent is required.

l Postprocedure care includes monitoring for airway patency, vital

signs, and urine output.

l Monitor for bleeding and infection.

l Encourage client to take oral fluids.

▪ •      Conscious sedations – morphine, fintanyl, versaid – quick

onset, short acting! Need a driver they can’t drive themselves

home; Invasive and inserting larger than typical cath, size 26

usually) – quick onset, short acting but leave loopy- risk for

FALLS;

Renal Arteriography (Angiography)-injection of dye in renal artery to show

blood flow into kidney

▪ •      Possible bowel preparation;

▪ •      Light meal evening before, then NPO

▪ •      Injection of radiopaque dye into renal arteries, √ allergies

▪ •      Assessment for bleeding

▪ •      Monitoring of vital signs

▪ •      FLUIDS

▪ •      Absolute bedrest for 4 to 6 hours

▪ •      Serum creatinine may be measured for several days to assess

effects of test/dye

▪ Remember all the allergies, etc. 

▪ Large cath inserted in femoral artery and gone up the renal artery inject

dye, check for hemmorage (big cath in big artery) First when pt back

do vital signs and check insertion site and palpate site blood will go

back; Hr will increase and bp decrease with pallor, weak pulse –

HEMMORAHGE;  if pt is bleed & surrounding tissue is hard –

indurations; Interventions to prevent bleeding pt must remain at bed

rest supine with leg straight hob elevated not more than 30degrees; 

force fluids, etc.;

▪ Question: An expected outcome for the pt who has undergone a renal

arteriogram is

▪  A) maintaining bedrest for 12 hr

▪ B) Maintaining the leg in a straight position for 12 hours

▪ C) Discouraging ankle flexing and wt shifting  

▪ D) measuring serum creatinine for several days

Answer: D

When creatinine gets around a 7 creatinine they are exhibiting uremia

symptoms;  Diaylsis is usually instituted around this time (Pt could have a 3

creatinine but could still need dialysis due to other factors like electrolytes)

-          *** (STORYTIME) Compartmental syndrome – (upper arms in football

players) swelling in tissue (impairs arterial circulation, below arm impaired,

death of muscle protein finally, dead muscle releases rhabdomyolysis, this

rhabdo causes renal failure, so those football players were at risk for ARF; ;;;

89 yr old brother caregiver for 91 yr old sister, 89yr old put sis to bed buddle

up and put her to bed but he feel and remained in floor overnight eventually

found but since it was winter with no heat he laid in a cold environment for a

long amount of time and he became hypothermic severe rhadomyolsis,

etc.;;;;

Renography

▪ •      Small amount of radioactive material, a radionuclide, used;

not radioactive, no safe precautions needed;

▪ •      Procedure via intravenous infection

▪ •      Follow-up care:

l Small amount of radioactive material may be excreted = force

fluids

l Maintain standard precautions.

l Client should avoid changing posture rapidly and avoid falling.

5 P’s Pain, Pulse Pallor, Paresthesia, Paralysis (Look at pictures on

Blackboard)

Percutaneous Renal Biopsy

▪ •      Clotting studies

▪ •      Preprocedure care

▪ •      Follow-up care

l Assessment for bleeding for 24 hours

l Strict bedrest

l Monitoring for hematuria

Increase Comfort measures after procedure

Insertion of long needle thru skin (back) and poke and pull out a piece of

tissue (bleeding is a complication) place pt on back or sandback to put

pressure on kidney biopsy; vitals to assess for hemorrhaging; strict bedrest,

watch urine for blood b/c if so the kidney is bleeding;

Question: A priority assessment of a pt who had kidney biopsy include:

A) assess for compliance w/ strict bedrest

B) assess for signs of hypovolemia

C) Monitor for hematuria

 D) assess for pain;

                Answer: B; at risk for bleeding ad hemorrhage

E. coli: medicine for that is gentamycin but this is nephrotoxic and ototoxic;

ARF- SUDDEN ONSET, reversible,   ESRD/HD end stage renal disease; 

Question: A pt w/ ESKD has serum lab analysis: K+ 5.9 mEq/L, Na+ 152

mEq/L, creatinine 6.2mg/dL, BUN 60 mg/dL. A priority intervention would be:

A) Assess heart rate and rhythm. 

B) Contact the Dr

C) Prepare the pt for dialysis therapy

 D) Evaluate pt resp stat E) Weigh Pt

Answer: A: Potassium is very high!!

K+ is the most lethal problem with the labs so check cardiac.

Interventions for Clients with Acute & Chronic Renal Failure  Chapter

71

Acute Renal Failure= ARF SUDDEN ONSET!!!

▪ •    Pathophysiology- rapid decline in function

▪ •    Types of acute renal failure include:

–  Prerenal (cause = decreased perfusion)

–  Intrarenal =Intrinsic = ATN (cause = meds, bacteria, NSAIDs, &

pre/post renal)

–  Postrenal (cause = obstruction to urine flow)

30 urine per hr if not red flags should be up that something is wrong with

renal

Intervention: bolus with fluids; diuretic; dopamine to improve blood flow;

acute tubular necrosis –

Phases of ARF

▪ •    Phases include:

–  Onset – precipitating event (First thing lost by kidney is lost to

concentrate urine);

–  Diuretic (non-oliguirc) non-oliguirc is that they are excreting water

just not the metabolic wastes

–  Oliguric /anuria Less than 30ml hour/no urine;  RISK FOR FLUID

OVERLOAD, hyperkalemia (no more OJ); Kayexlate orally or rectally –

it’s a Na, high sodium on one side and Potassium goes into Gut

which is good but we don’t want that much Sodium in body so we

mix it with a hypoosmolar that’s a sugar to even it out because

water will be pulled in and sodium will follow, pt K+ will go down

and the pt will poop a lot;  Insulin pushes sugar in the cell and K

goes with the sugar so by giving insulin potassium will follow, give

reg insulin IV if you do this an the pt does not need insulin with their

sugar level you can give 50% dextrose with it;

–  Recovery

▪ •    Acute syndrome may be reversible with prompt intervention.

Assessment

▪ •    History – precipitating event

▪ •    Clinical manifestations- depends on phase/type (could be

hypo/hypervolemia); Increasing K, P, Mg and decreasing Ca &

GFR

▪ •       Laboratory assessment ↑Creatinine, BUN, K+, Phos, Mg++;

↓Cr Clearance, Ca++

▪ •    Radiographic assessment

▪ •    Other diagnostic assessments such as renal biopsy

Interventions:

▪ •    Prerenal

–  Fluid bolus

–  Diuretics

▪ •    Intrinsic=Intrarenal

–  Low dose Dopamine (~3 mcg/kg/min)

–  Monitor fluid volume status

–  Calcium Channel Blockers (improve renal blood flow)

–  Monitor for medication toxicities; dose adjustments

▪ •    Postrenal

–  Remove/bypass obstruction to urine flow

Medication Considerations

▪ •    Cardioglycides = digoxin toxicity = ↓ dose

▪ •    Vitamins and minerals-may need B9 & iron – boost all the blood

▪ •    Biologic response modifiers= Epogen (Erythropoietin)

▪ •    Phosphate binders= Amphojel to ↓ phos absorption, TUMS to

↑Ca++

▪ •    Stool softeners and laxatives

▪ •    Diuretics

▪ •    Calcium channel blockers & HBP control; dilate renal artery;

DON’T TAKE ANYTHING WITH OTHER STUFF IN IT!! Fleets phosphate

or milk mag, etc, they cant excrete these; 

K+ management

Treatment

▪ •    Diet therapy

–  Protein intake – according to client needs

–  Watch foods high/low in electrolytes of concern

–  Watch fluid intake

–  If elemental or TPN needed – special Renal Formula

 

▪ •    Dialysis therapies

–  If needed for fluid, electrolyte, azotemia control

–  Hemodialysis

–  Peritoneal dialysis

–  ‘Continuous Renal Replacement Therapy’ (for fluid overload)

Posthospital Care

▪ •    If renal failure is resolving, follow-up care may be required.

▪ •    There may be permanent renal damage and the need for

chronic dialysis or even transplantation.

▪ •    Temporary dialysis is appropriate for some clients.

▪ •    May take ~ 1 year to resolve

 

Chronic Renal Insufficiency          Failure            ESRD         

▪ •    Progressive, irreversible kidney injury;  kidney function does

not recover

Changes in Chronic Renal Failure → ESRD

▪ •   Metabolic – azotemia -> uremia – causes HTN, creatinine is a

irritant (infects mucous membranes and linings of all organs)

the <3 has the worst effect;

–  Urea and creatinine  (around 7)

▪ •   Electrolytes

–   Sodium  (hyponatremia/hypernatremia)          

–   Potassium (hyperkalemia)

▪ •   Acid-base balance

▪ •   Metabolic acidosis

▪ •   Calcium and phosphorus

▪ •   Hyperphosphatemia/hypocalcemia

 

Clinical Manifestations

▪ •    Neurologic: lethargy - coma

▪ •    Cardiovascular: HBP, CHF, P E, dysrhythmias; “rub”; high

hyperlipidemia; uremic pericarditis

▪ •    Respiratory: tachypnea, pleurisy

▪ •    Hematologic: anemia, bruising; Low WBC & Platelets;

▪ •    Gastrointestinal: bleeding, ulceration, hiccups, 

▪ •    Urinary: decreased output

▪ •    Skin: yellow/gray discoloration, pruritus, frost, ecchymoses

▪ •    Sexuality: infertility, dryness, impotence

Proton pump inhibiter (protonix); lining should be resonance but if there is

fluid it will be dull;

Hemodialysis – there is a blood that flows to dialyzer, and the hemodialyzer

(where the filtering takes place);  Blood flows back to body;

Give heparin and get PTT’s done;

▪ If a heparin pt has dialysis and needs a thorascentis do the thora first

before the heparin; so give protamin sulfate to reverse the heparin; 

heparin stays active 6hr; if air or dialysate got in the airway it would

shut down;

Vascular Access

▪ •    Arteriovenous fistula, or arteriovenous graft for long-term

permanent access

▪ •    Hemodialysis catheter, dual or triple lumen, or arteriovenous

shunt for temporary access

▪ •    Precautions: no restrictive clothing, tourniquets, NO   BP, IV, or

blood draw

▪ •    Complications: clotting (= loss of access= no HD), infection

▪ •    Listen for bruit, palpate for thrill; Assess any vascular assess

devices- listen for bruit, (sounds like a little air gun) 

Hemodialysis Nursing Care

▪ •    Postdialysis care:

–  Monitor for complications such as hypotension, headache, nausea,

malaise, vomiting, dizziness, and muscle cramps (disequilibrium

syndrome).

–  Monitor vital signs and weight.

–  Avoid invasive procedures 4 to 6 hours after dialysis.

–  Continually monitor for hemorrhage.

–  Administer meds that were held prior to dialysis: HBP, dialyzable

antibiotics, digoxin, etc

There is an unequal another of creatinine in the CSF and serum (eventually

they will diffuse and be equal) BAD CSF problems.  SS above. 

HOLD MEDS PRIOR TO DIALYSIS OTHERWISE THEY WILL GO OUT!!

Peritoneal Dialysis

▪ •    Procedure involves special catheter placed into the abdominal

cavity for infusion of dialysate.

▪ •    Types of peritoneal dialysis:

–  Continuous ambulatory peritoneal

–  Automated peritoneal

–  Intermittent peritoneal

–  Continuous-cycle peritoneal

PD more closely mimics the kidney it just doesn’t make Vit D and

erythropoietin;

Complications            

▪ •    Peritonitis

▪ •    Pain

▪ •    Exit site and tunnel infections

▪ •    Poor dialysate flow

▪ •    Dialysate leakage

▪ •    Other complications

Nursing Care During Peritoneal Dialysis

▪ •    Before treating: evaluate baseline vital signs, weight, and

laboratory tests.

▪ •    Continually monitor the client for respiratory distress, pain,

and discomfort.

▪ •    Monitor prescribed dwell time and initiate outflow.

▪ •    Observe the outflow amount and pattern of fluid.

Complications of Hemodialysis

▪ •    Dialysis disequilibrium syndrome

▪ •    Infectious disease

▪ •    Hepatitis B and C infections & HIV exposure—poses some risk

for clients undergoing dialysis & staff

Cost, time

Renal Transplantation

▪ •    Candidate selection criteria

▪ •    Donors

▪ •    Preoperative care

▪ •    Immunologic studies

▪ •    Surgical team

▪ •    Operative procedure

Postoperative Care

▪ •    Urologic management

▪ •    Assessment of urine output hourly for 48 hours.

▪ •    Complications include:

– Rejection

▪ •  S/S: increased  Temp, BP, pain, UO,  Cr/BUN,  weight

– Acute tubular necrosis

–  Thrombosis

–  Renal artery stenosis

–  Other complications

–  Immunosuppressive drug therapy

–Psychosocial preparation

Cystitis & Infections of Lower Urinary Tract (Chapter 69)

▪ •    Inflammation of the bladder

Most commonly caused by bacteria (or viruses, fungi, or parasites ) from the

rectum/vagina moving into the external urethra to the bladder, ureter, &

even to the kidney (pyelonephritis)

E. Coli is the most common bacteria

Catheter related infections common during hospital stay

▪ •    HIGH RISK: UROSEPSIS with high mortality

UTI – Urinary tract infection – inflammation of lower urinary system (FOLEY

CATH is highest in hospital) Women are more likely to get it because urethra

is shorter & Perneal area so close;  Men get it due to enlarged prostate b/c it

obstructs urine;  (Empty bladder q 3 hr) 

Cystitis – visible vessels, lots of tiny red dots, hemorrhagic area from

infection;

Most common sign is: FREQUENCY: PAIN (burning);

Incidence and Prevalence of Cystitis

▪ •    2nd most common reason to visit to HCP

▪ •    ASSESSMENT

–   Frequent urge to urinate

–   Dysuria

–   Urgency

▪ •    UA needed to test for leukocyte esterase (+ in UTI), also WBCs,

RBCs (WBC URINE CLOUDLY)  (SMOKY or pink/red if RBC in

urine) 

For older adults in the hospital, the 1st sign is altered mental status. 

Type of organism confirmed by urine culture

↑serum WBCs with ↑ in ‘bands’ (adolescent WBC)

      When we are faced with an infection bone marrow will release adolescent

aged WBC to help the “tired already in circulation” WBC; should not have

these “bands” unless we are sick; LOOK AT TYPE OF WBC (are they in

the correct proportion) Bandemia

      E. coli is the most common type of bacteria found as a cause of

UTI;

CYSTO to R/O abnormalities

Pharmacological Therapy

▪ •Urinary antiseptics: Macrobid, Macrodantin (nitrofurodantin); Pt will

frequent recurring UTI may have a low dose daily; this decreases

bacteria growth

▪ •Antibiotics: Septra, Cipro, Levaquin, Amoxil, Duricef

▪ •Analgesics: Pyridium (overcounter med) Orange color urine; will diminish

burning but doesn’t address cause; drink LOTS of liquids;

▪ •Antispasmodics: Anaspaz (b/c the bladder is irritated so it needs

something to diminish the spasm)

▪ •Antimicrobials: Bactrim/Septra, Cipro/Levaquin, Amoxil, Duricef

▪ •Antifungal agents: Nizoral

Long-term antibiotic therapy for chronic, recurring infections

▪ •Intravaginal Estrogen for postmenopausal women (general dryness as

women age) cream or tablets

QUESTION: What is an expected outcome for the older adult male pt

with a history of asthma who is being treated w/ nitrofurntin

(Macrobid)?

1.A.    Orange-colored urine

2.B.     Constipation

3.C.     Blurred vision

4.D.    Flu-like symptoms;

Answer: D - monitor these symptoms in older pt taking

nitrofurantoin and those with pulmonary disease;   

Nonpharmacological Management

▪ •    Urinary elimination after sex & before bedtime

Urinate q 3-4hr                                                

▪ •    Diet therapy:  all food groups, ↑ calorie RT ↑ increase in

metabolism caused by the infection; ↑ intake 2-3 L/day of

fluids, possible intake of cranberry juice; d/c caffeine; Vit C

foods/fluids

▪ •Other pain relief measures, such as warm sitz baths but not

vigorous cleaning of perineum or douching

▪ • Cotton undies/no tight jeans

▪ •Daily perineal cleansing (but not vigorous cleaning, douching or bubble

baths) 

Question: 21 yr old male complaining of burning and difficulty with

urination.  Priority question in obtaining info about pt chief complaint would

be:

1.How long have you had these symptoms?

2.Do you have low back pain?

3.Are you sexually active? 

4.Have you had fever in past 24 hr

Answer: C  Most common cause of urethritis in men is STD: Ureaplasma,

Chlamydia or Trichomonas vaginalis!!

Can lead to pylenephritis & Urosepsis ; Altered mental status

(decreased blood flow to brain)

Urinary Incontinence

▪ •    Impacts > 13 million in USA. Mostly ♀

▪ •    Not a normal result of aging, but does ↑ with age

▪ •    Five types of incontinence include:

–   Stress – little when coughing, sneezing, vomiting; 

–   Urge – Cant make it to the bathroom

–   Mixed

–   Overflow – spinal cord injury, bladder wont empty and it starts to

leak

–   Functional (cognitive impairment) Don’t know when to recognize

when its time (Dementia, unresponsive individual)

The brain sends nerve signals telling muscles to hold urine or let it out. 

Nerves send signals to the brain.  Signals tell when the bladder is full or

empty.  

Collaborative Management

▪ •    Assessment: thorough client history (make sure not

constipated)

▪ •    Clinical exam to R/O cystocele (herniation of bladder into

vagina), rectocele, prolapsed uterus & assess perineal

sensation; medication history

▪ •    Urinalysis: R/O infection

▪ •    Radiographic assessment & other diagnostic assessments to

determine urinary system health

(Lightly touch anus, contract when it touch, if it doesn’t contract then they

may have nerve root problem to bladder)

▪ •    Interventions include:

–   Keeping a diary

–   Behavioral interventions

–   Diet modification: weight loss, no caffeine, alcohol

–   Pelvic floor exercises (Kegels)

–   Drug therapy: Estrogen, Pro-Banthine, Ditropan, Detrol (increase

intraocular Pressure) see eye dr. can cause glaucoma; Trofranil-

Antianxiety and has anticolingeric; all these meds cause DRY

MOUTH, URINARY RETENTION

–   Vaginal cone weights

–   Urinary habit training (freq basis)

–   Intermittent self-catheterization (clean technique)

–   Containment of urine and protection of the client’s skin

–   Applied devices: penile clamp, pessaries (object place inside

vagina that cystisilfallen bladder, take out clean etc), condom

Last resort: Urinary catheterization

Surgical Management

▪ •    Preoperative care (Abdominal surgical procedure)

▪ •    Operative procedure: see list pg 1692 (1. Inject collagen which

works 50% of the time. 2. Surgery to pull bladder back to be

surgically correct (bladder tack-up) 3. Suprapublic cath)

▪ •    Postoperative care (Airway #1, at risk for pneumonia b/c they

won’t want to deep breath due to pain; Circulation: DVT (calf

pain edema & pulmonary embolism is main concern which pt

has chest pain SOB and alter gas exchange)

–   Assess for and intervene to prevent or detect complications.

–   Secure urethral or suprapubic catheter.

–   No sex until post-op check (~6 wk) to allow good healing

–   No heavy lifting for 3 months (5lbs)

–   No exercise such as running, aerobics, stair-climbers until

completely healed

Any pelvic surgery puts them at higher risk for DVT (ambulation,

antiembolism stockins, etc.)

Urolithiasis

▪ •    Presence of calculi (stones) in the urinary tract

▪ •    History of urologic stones

▪ •    Clinical manifestations ---- EXTREME pain when stone moves

NCLEX says pain is a psychological diagnosis so if this appears, it’s most

likely not the number 1 choice.

▪ •    Laboratory assessment: -- UA, ↑WBC if infection

▪ •    Radiographic assessment:  CT of abdomen, (IVP)

Pain when stone actually moving; (pain location depends, if stone in pelvis is

in back, upper ureter in upper side and when it starts moving down it starts

moving toward the bladder) 25 yr old female pain in right lower abdomen

(ectopic preg, appendicitis, ovaries problems) Have pt go for cat scan b/c the

IVP (needs bowel prep) will not be bowel prep;

Stones make WBC go up just like infection does; 

Question:  A pt with urolithiasis has not voided in 7 hr.  What is primary

concern for this pt?

1.Hematuria

2.Hydronephrosis (water on nephron);

3.Infection

4.Pain

Risk for blockage; risk for infection (physiology) Pain; 

Answer: B - A primary concern is prolonged obstruction.  As the blockage

persists, hydronephrosis and permanent kidney damage may develop.  Other

concerns with urolithiasis include infection, hematuria, and effective tx of pt

pain

Interventions

▪ •    Drug therapy often with Opioid analgesics (morphine) IV;

Watch for resp distress; constipation

▪ •    Nonsteroidal anti-inflammatory drugs

▪ •    Pain medications at regular intervals

▪ •    Constant delivery system

▪ •    Spasmolytic drugs (Ditropan & Pro-Banthine)—important for

relief of pain

▪ •    Complementary and alternative therapy

Anticipate pt to be on increase Fluids (rates greater than typical amt) Watch

for fluid vol overload; get a filter or strainer; Pt probably nausea  and

probably on an antibiotic to prevent infection;

Lithotripsy

▪ •    Extracorporeal shock wave lithotripsy uses sound, laser, or dry

shock wave energy to break the stone into small fragments.

(Sound waves used outside of body to crush stones so that

they can move) sore abdomen with bruising, hematuria; tell pt

to ice the abdomen etc

▪ •    Client undergoes conscious sedation

▪ •    Topical anesthetic cream is applied to skin site of stone.

▪ •    Continuous monitoring is by electrocardiography

Surgical Management (Cysto – scope thru bladder up ureters and

using implement with a loop try to get above stone and scoop it

down) expect pain, hematuria, inflammation;

▪ •    Minimally invasive surgical procedures

▪ •    Stenting; after scraping there will be a stent (small tube) to

keep ureter open until inflammatory response stops; there

may be string out peepee hole :] make sure pt don’t put out

string b/c that will remove stent; (week to ten days

inflammation)

▪ •    Retrograde ureteroscopy

▪ •    Percutaneous ureterolithotomy and nephrolithotomy

▪ •    Open surgical procedures

–   Preoperative care

–   Operative procedure

Postoperative Care

▪ •    Routine postoperative care procedures for assessment of

bleeding, urine, and adequate fluid intake

▪ •    Strained urine

▪ •    Infection prevention

▪ •    Drug therapy

▪ •    Diet therapy

▪ •    Prevention of obstruction

Drug Therapy

▪ •    Drug selection to prevent obstruction depends on what is

forming the stone:

–   Calcium; Low Ca diet, hydrodiurl promotes resorption of Ca into

blood

–   Oxalate; Low oxalate diet; zyloprim, vit B6

–   Uric acid; metabolic disease GOUT makes kidney stones, low

purine diet (low in proteins and greens) Med allopurinol often given,

also probencid

–   Cystine – hydration, alkalinazation, captopril

Urothelial Cancer – abnormal growth of abnormal cells

▪ •    Collaborative management

▪ •    Assessment

▪ •    Diagnostic assessment

▪ •    Nonsurgical management

–   Prophylactic immunotherapy

–   Chemotherapy

–   Radiation therapy

Prevention of Bladder Cancer- Protect self against inhaled chemicals; drink

lots of fluids & void freq; extra Vit A (protectant); NO MARIJUANA  or

cigarettes (its an irritant to bladder)

Tx of bladder cancer: Intravesical Chemotherapy  (medication instilled into

the bladder – intravesical – through a foley medicine get up there and the

foley will be clamped so medicine will get contact with bladder lining and

cancer (NPO, so it wont dilute the medicine) SAVE bladder, drug is not

absorbed and will not have side effects to rest of body;

Surgical Management – if cancer is stage 4 and taking bladder out is

a must;

▪ •    Preoperative care

▪ •    Operative procedures – preserve bladder if possible; if not ->

cystectomy & ileal conduit; ileal conduit, urostomy – take out

bladder and resect 6in of bowel and create tube (one end is

closed the other end is brought to skin –stoma – ureters are

implanted into the tube and urine will flow to the stoma

constanly) this pt will be incontinent – flowing of urine

constantly (POUCH)

▪ •    Postoperative care includes:

–   Collaboration with enterostomal (WOCN) therapist

–   Kock’s pouch or Indiana pouch – took segment of bowel and made

pouch and the connected tube and got a stoma – this pt is continent

– Advantage is that its continent; pt will cath pouch every 4 hrs, no

external pouch needed and learn sense of fullness (in right quad)

Disdvantage – special surgeon, longer surgery time,

–   Neobladder – make new bladder if ureters weren’t affected with

cancer, less common;

Nursing – assess skin around stoma, not red or inflamed; stoma pink, moist

(look like lining of mouth) Constant flow of urine;

Urostomy Stoma & Pouches

Nephrostomy- tube placed into pelvis of kidney, pouch system with stent

draining urine in pouch; high risk for infection; 

Question:  Pt with hydronephrosis she had nephrostomy tube placed. Which

assessment data requires immediate intervention and notification of Dr?

1.Hematuria

2.Cloudy Urine

3.Pt complaint of back pain  

4. Pot 4.9

Answer: C  if the amt of drainage decreases and the pt has back pain, the

nephrostomy tube may be clogged or dislodged.

Ureterostomy – bring ureters out to skin

Crystals:  Occur when urine is too alkaline. Can cause stomal irritation and or

bleeding. Urinary crystals can be prevented by keeping it clean;

Bladder Trauma

▪ •    Causes may be due to injury to the lower abdomen or stabbing

or gunshot wounds.

▪ •    Surgical intervention is required.

▪ •    Fractures should be stabilized before bladder repair.

Frank – very red!!! NOT GOOD;;

Interventions for Clients with Renal Disorders   Chapter 74

Polycystic Kidney Disease

▪ •      Inherited (autosomal dominant) disorder in which fluid-filled

cysts develop in the nephrons – 50% chance of getting it;

▪ •      Key features include:  Causes cysts to form in the kidney

–  Abdominal or flank pain (swelling of kidney) – diminished blood

flow releasing renin

–  Hypertension from release of renin

–  Nocturia can’t concentrate urine

–  Increased abdominal girth from swelling of kidney

NO CURE!!

Prevent complication

Genetic Testing

KIDNEY TRANSPLANT!!!!

PKD DIAGNOSIS

Ultrasound

CT

MRI

Genetic history

Urinalysis (protein & blood)

Decreased kidney function

Interventions

▪ •      Pain management- caution NSAIDs

▪ •      Bowel management- constipation from enlarged kidneys

▪ •      Medication management - ACE inhibitors & other HBP meds

▪ •      Energy management

▪ •      Fluid monitoring – low Na+ diet

▪ •      Urinary retention care – Credé –emptying bladder by manually

pushing or pulling butt hairs (may have incontinence)

▪ •      Infection protection

Question:  A possible outcome for the pt being treated with spironolactone for

nephritic syndrome is the development of

A)      Hyponatremia

B)      Hyperkalemia

C)      Hypercalcemia

D)     Hypophosphatemia

Answer B

Pyelonephritis (chapter 74)

▪ •      Bacterial infection in the kidney (upper urinary tract)

▪ •      Key features include:

–  Fever, chills, tachycardia, and tachypnea

–  Flank, back, or loin pain

–  Abdominal discomfort

–  Turning, nausea and vomiting, urgency, frequency, nocturia

–  General malaise or fatigue

▪ •      Hypertension

▪ •      Inability to conserve sodium

▪ •      Decreased concentrating ability

▪ •      Tendency to develop hyperkalemia and acidosis

More likely in females!!

Acute Pain Interventions

▪ •      Pain management interventions

▪ •      Drug therapy

–  Antibiotics

–  Urinary antiseptics (macrodantin)

▪ •      Diet therapy

–  Force fluids

Surgical Management – for structural problems

▪ •      Preoperative care

–  Antibiotics

–  Client education

▪ •      Operative procedure: pyelolithotomy, nephrectomy, ureteral

diversion, ureter reimplantaton

▪ •      Postoperative care for urologic surgery

Glomerulonephritis= Nephritic Syndrome

▪ •      Assessment ~ 10 days after infection usually Streptococcus

(resulting in antibody/antigen reactions within glomerulus); 

edema (if protein not in vessel water leaks into interstial),

proteinuria, hematuria HBP, fatigue, ↓GFR,↑BUN/Cr, + Strep

titers

▪ •      Management of infection

▪ •      Prevention of complications

–  Diuretics

–  Sodium, water, potassium, and protein restrictions

–  Dialysis, plasmapheresis

–  Client education

Chronic Glomerulonephritis --  Results in loss of nephrons leading to

↓GFR → renal failure

Question: Male pt complains of progressive fatigue, anorexia, wt gain and

dysuria with dark colored urine what is the priority nursing care?

1.Do you have family hx of renal disease

2.Have you had recent infection

3.Do you experience freq UTI

4.When did you first notice symptoms

Answers: B   :  The onset of symptoms is 10 days from time of infection. 

Systemic strept infection is more common in men as precursor infection of

acute glomerulonephritis

Nephrotic Syndrome

▪ •      Condition of increased glomerular permeability that allows

larger protein molecules to pass through the membrane into

the urine and be removed from the blood

▪ •      Severe loss of protein into the urine; larger molecules

Proteinuria; lots of bubbles in toilet; plum (periorbital edema) sclera edema;

chest for pulmonary edema;  (AIR IS BLACK ON CHEST X-RAY); STREP

▪ •      Treatment involves:

–  Immunosuppressive agents (Reverse/Protective Isolation –

neutropenic) Wear mask, gloves, gown AT RISK FOR INFECTION

–  Angiotensin-converting enzyme inhibitors

–  Heparin

–  Diet changes

Rest!

-          Mild diuretics

Question: The older adult pt with acute glomerulonephritis is often

misdiagnosed with

1.CVA

2.Transient ischemic attack

3.Aortic aneyrysm

4.CHF

Answers: D

Renal Trauma

▪ •      Minor injuries such as contusions, small lacerations

▪ •      Major injuries such as lacerations to the cortex, medulla, or

branches of the renal artery

▪ •      Collaborative management

▪ •      Nonsurgical management: drug therapy and fluid therapy

▪ •      Surgical management: nephrectomy or partial nephrectomy

BLEEDING major problem if there is trauma; prep for blood transfusion,

surgery, etc.  Don’t want to overstress kidneys after this kind of accident!

Renal Cancer

Stage 1 7cm; Stage II 7Cm; Stage III Gerota’s fascia; Stage IV other organs

and lympg nodes

Cancer is abnormal growth of abnormal cells; SPREAD to other body organs

(the spread to the lung, etc. is usually when manifestation starts;  Cure rate

for renal cancer is not really high; difficult to treat b/c we don’t find the

disease early;

Tx: Remove diseased kidney f (long incision from diaphragm to center of

abdomen and all around sides; Have to spread all those kidneys;  PT coming

straight from surgery #1 priority is AIRWAY, BREATHING, CIRCULATION

(watch for hemorrhage, vitals, pulse quality, skin color, output from drain, 

the hr after pt comes back should be sangious, 48hr after it should be sero-

sang, BUN and creatinine should stay normal; Pain should be the next

concern;

Nephrectomy: Traditional vs  Laproscopic 

Lapro: less heal time, not as painful, smaller scars;  (CO2) - absorbed by

body, shoulder pain; RISK for bleeding b/c they can’t see. 

 [KE1]MAP = (2 X DP) + SP/ 3

410 Lectures

-          Over 2 millions nephrons; As we age the cortical nephrons are

nonfunctionals and so we lose nephrons.

-          ***KNOW THE PARTS OF A NEPHRON;  The start is Bowman’s capsule

and that makes up the glomerulus (beginning stages of urine formed there-

filtration) this network of capillaries have a semipermeable membrane (in a

normal environment the membrane don’t allow protein), filtrate results from

filtration; filtrate is like serum w/ the exception of protein (watery clear part

of blood without RBC);

-           Strept throat (the bacteria can cause a antibody response in the

glomerulus), Hypertension, UTI & Diabetes(damage membrane) sometimes

causes protein to get into the filtrate, once its in the filtrate it is lost in urine

and no longer in the body; (Pregnant women with proteinurea will have  a

decrease amt of serum protein) All these things can damage the glomerulus

and Bowman’s capsule;

-          What is the consequence of having low serum protein?  Delivery of

medication, muscle and cell problems, slow healing, **Risk for delayed

healing rt to low serum protein from proteinurea;

Now Check for edema esp. in face w/ these patients (water was leaving the

cells, protein holds water in the intravascular compartment) Also, skin

integrity rt fluid in interstitial space;  capillary refill will be sluggish, skin color

pale b/c less blood supply, mental status altered; Water is all in the intestinal

space, intravascular vol deficit w/ interstitial volume excess- fluid is in wrong

space all b/c protein is gone;

▪  Give this pt a hypertonic soln or give pt shot of protein (albumin);  If it

works pt will have stronger pulse and bp and urine will increase, less

edema, better capillary refill

-          Second part of nephron is PCT – proximal convulted tubule,  (120 mL

per min forming filtrate) 90% of what is filtered is reabsorbed, surrounding

the PCT is an arteriole and the products move back into the blood; 90% of

whats filtered is reabsorbed;

▪ If the PCT is broken the urine volume will INCREASE!  The volume in our

body will be low… decrease pulse, bp, cold clammy skin, etc.  If

potassium cant be reabsorbed it will be low in the serum along with

other electrolytes

-          The third is the Loop of Henle it concentrates urine (Loop Diuretics

work here and block the reabsorption of sodium, which water follows); 

-          The DCT is next, Distal convulated tubule, the primary role is

secretion; vesicles around DCT pick up any extra concentrated electrolytes

back into the nephron after they were reabsorbed; 

▪ ADH has its effect on the DCT, water is reabsorbed and not secreted into

the urine; 

-          The fifth part is the collecting duct, it transfers the filtrate to the

renal pelvis. FINAL part of the tube and now the filtrate is called URINE;

-          Urine then flows down the ureters to the bladder into the uretha to

EXCRET so the collecting ducts are for excretion;

-          Question: Which pt is more likely to experience renal compromise

(decreased urine production)? 

▪ A pt w/ blood pressure of 92/45 for 12 hr

▪ A pt w/ white blood cell count of 12,000 (5-10,000 – normal)

▪ A pt w/ 5 yr hx of DM

▪ A pt w/ hx of myocardial infection

-          The ANSWER is A b/c this blood pressure has a mean arterial pressure

(MAP[KE1] ) of 62 mm hg. The kidney has a difficult time regulating GFR w/ a

MAP less then 65 mm Hg; If this was my pt from ER  what would we see if

fluid vol overload, increased resp rate, nasal flaring, HOB elevated, pulse

oximeter, crackles in lung sound or rales, so primary for this pt would be

pulmonary; Next Cardiac mayb distended neck veins, puffy & edema, could

have pounding pulse w/ increased rate,  will hear S3 (APEX is where this will

be heard)

-          Filtration must have adequate blood flow and pressure, when pressure

falls vol of filtrate decreases and vol of urine decreases which can cause fluid

overload b/c all of it is retained.  Prolonged hypotension can cause fluid

overload. Failure to filter is retention in the body, so electrolytes will go up,

like Potassium (meaning Cardiac should be evaluated when something is

wrong with filtration)

Bicarbonate Reabsorption

▪ •      Secretion of hydrogen ions

▪ •      Secretion of nonvolatile [acids that do not form a gas] acids

(phosphate, ammonia, urea, etc)

STORY - COPD pt have CO2 trapped and our levels increased which leads to

elevated carbonic acid; If this pt had healthy kidney it would recompensate

for it by holding onto bicarbonate and secrete other acids like ammonia but

when we have renal problems the kidney can’t do this and if it cant do that

the bicarb goes in the urine and the body has a low bicarb level This pt will

get bicarb tablets w/ pt having high resp rate b/c lungs tries to get rid of it;

** IF this was Pt is in fluid vol excess & have fluid in alveoli (resp rate goes

up);  This pt will be sicker b/c they cant blow off the CO2;  ( This pt would be

at risk for pneumonia, if a pt came in with or at risk for other respiratory

problems on top of renal problems & COPD they would be closer to nurse

station bc they are so prone to getting acidosis) 

Make and reabsorb bicarb and secrete others like ammonia. 

Renal Failure → Metabolic Acidosis

Regulation of Blood Pressure

▪ •      Production of Renin – regulates blood pressure

▪ Renin is produced when there is a decrease in blood pressure into the

kidney;

▪ •      Structures within the DCT (macula densa cells – lie beside

renin producing cells) sense decrease perfusion/pressure --

release renin -- renin converts angiotensinogen (from liver)

into Angiotensin I which converts (in lung) into Angiotensin II

(increases afterload & stimulates release of Aldosterone (from

adrenal) to enhance sodium reabsorption (pg 202)

▪ •      Renal Failure -> often hypertension

▪ CHF has less CO and less blood flow to kidney, with Renin in these people

the vessel are constricted which causes it to have even more decrease

in the CO, this is when we start meds like lisinopril (ACE INHIBITOR)

they block angiotension I to angiotension II which ultimately causes

less constriction.  People who come in after accidents taking this med

is the most important.

▪ Aldactone – Potassium sparing diuretic; if you give this you are blocking

Aldosterone which is blocking sodium reabsorption meaning Sodium is

going to be urinated out & Potassium is reabsorbed; what should they

drink with aldactone? Water, OJ, apple, pineapple?  Apple juice,

cranberry juice, water  (NO TROPICAL JUICES b/c they are high in

potassium)

Red Blood Cell Synthesis

▪ Produces erythropoietin: when oxygen delivery to kidney

decreased, erythropoietin is released which stimulates the

bone marrow to release RBCs into the circulation

▪ Renal failure → chronic anemia

The renal failure pt will have problem making this and will exhibit anemia

hemoglobin less than 12;  these pt have low oxygen;  How would you

evaluate a Hemoglobin of 8 (perform ADL w/out shortness of breath, absence

of heart pain & arrhythmias, Confusion due to not enough blood to brain,

seizure)

Epogen, Procrit – if these are effective hemoglobin level goes up, no

confusion, etc. 

Place these pt close to nursing station bc of low oxygen delivery to body due

to anemia!! Angina or arrhythmias from low o2 to heart; rest b/t activities;

diminished oxygen to body results in fatigue, SOB when carrying activities;

QUESTION:  A pt with renal failure is complaining of dyspnea.  The pt pulse

ox reading is 96% on room air.  However, the pt is visibly distressed with a

respiratory rate of 32 breaths/min.  A priority intervention would be:

A)     Elevate HOB 90 degrees

B)      Notify the respiratory therapist

C)      Administer a resp nebulizing treatment

D)     Administer Oxygen by NC

Answer: D high oxygen sat is an anemic pt that is showing signs of resp

distress may still be hypoxemic.  Thus administering oxygen is necessary. 

Conversion of Vitamin D (necessary for Ca++ absorption)

Ultraviolet light converts 7-dehydrocholesterol in skin to

cholecalciferol Kidney (& liver) hydroxylates this vitamin D into an

activated form

-          Active Vit D is necessary for Ca absorption in the small intestine

-          Renal Failure -> Low serum Calcium; Decrease in bone mass

(osteoporosis) due to PTH acting on bones to extract calcium out of bones.

These pt will take Vit D and calcium tablets; Calcium is best absorbed w/

food; 

-          Teach pt about bone breakage, fall precautions; (take away rugs,

extension cords, get safety in bathroom, lighting, etc) FALL RISK PT; use pull

sheet vs. pulling on arms; heart muscle may have problems if low serum

calcium;  weak again risk for falls, peristalsis activity down and may get

constipation ALL B/C VIT D!!!  Coagulation, delayed so they bleed easy; TUMS

is the cheapest source of Ca but must give with food, also antacid for acid

reflux drugs so take this on an empty stomach;  Ca and P oppositely related,

Administer drug called PHOS-LOW when the Ca is low so this inhibits

Phosphorus absorption, Corn & Milk is high in Phosphorus, they can take the

phos-low so the phosphorus is inhibited so now they will just reabsorb Ca;

Basal-gal another phosphorus binding agent, block it from absorbing;   

Tubules: Filtration, Reabsorption, Secretion, Excretion &

Regulation of Electrolytes

Glomerulus – Filtration

Proximal Tutble- reabsorption

Loop of Henele – concentration of urine

Distal tubule- secrete

Collecting Duct – excrete

▪ Calcium 9.0-10.5 mg/dl

▪ •      Decrease in serum calcium stimulates secretion of PTH to

increase reabsorption of calcium & excretion of phosphate;

mobilization of calcium from bone

▪ •      ¯ Ca+ level from Vitamin D in Renal Fail.

▪ •      A ¯ Ca+ level can also occur from: 1) Corticosteroids (¯ Ca+

absorption),  2) Diuretics Ca+ excretion, 3) diet

Signs and Symptoms of altered calcium levels

Consequences of altered calcium levels

Regulation of Electrolytes

▪ •      Sodium – the major extracellular cation (norm =135-145

mEq/l)

▪ •      Sodium reabsorption increases

l Decreased GFR, Aldosterone secretion, action of Atrial natriuretic

peptide

▪ •      Sodium reabsorption decreases

l Increased GFR & excess ECF volume

l Secretion of ADH

l Loop-affecting diuretics

▪ •      Potassium (norm = 3.5 - 5.5 mEq/L)

▪ •      Major intracellular cation

▪ •      Factors enhancing potassium excretion

l Increase in cellular potassium

l Metabolic/respiratory alkalosis

l High urine flow rates

l Aldosterone

l Loop Diuretics

Other Electrolytes of Concern

▪ •      Phosphate

▪ •      Magnesium

▪ •      Need to know Signs and symptoms of electrolyte alterations,

consequences of electrolyte alterations, foods high/low in

these electrolytes; nursing implications

Changes in Kidneys Associated with Aging

▪ •      Reduced renal blood flow causing kidney loss of cortical tissue

by 80 years of age

▪ •      Thickened glomerular and tubular basement membranes,

reducing filtrating ability

▪ •      Decreased tubule length with decreased glomerular filtration

rate

▪ •      Nocturnal polyuria and risk for dehydration (volume deficit)

Collecting duct is first to go and there is an inability to concentrate urine,

NOCTURIA, polyuria, sleep deprivation, slower thinking, emotional instability,

memory is altered;

-         Consequences of changes:

Reduced ability to filter

Reduced ability to excrete waste products

Nephrons more vulnerable to damage from low or high BP/& or DM

Assessment Techniques

▪ •      Family history and genetic risk assessment – DM, HTN,

Polycystic kidney disease

▪ •      Demographic data and personal history- where you work,

chemicals that’s nephrotoxic, Fast food,

▪ •      Diet history- High sodium intake from so much fast food; diets

high in protein trying to lose wt,

▪ •      Socioeconomic status

▪ •      Current health problems: DM HTN, etc. Meds toxic to kidneys

nonsteriodal anti-inflammatory (ibuprofen, Advil, Motrin,

Aspirin, all the general aches and pain w/ exception of Tylenol)

most arthritis drugs, ace inhibitors, loop diuretics, antibiotics

(REALLY NEPHROTOXIC),

Question:  A pt with hx of renal disease is admitted with acute shoulder

pain. Which order should the nurse question?

1.Pan cultures for temp >38.5 c

2.Metoprolol (beta blocker) 50mg by mouth BID

3.Ibuprofen 600mg by mouth every 8 hr as needed for pain: nurse could

suggest Tylenol

4.Digoxin 0.125 mg daily

Answer C: these are nephrotoxic and should not be given to a renal patient

Physical Assessment

▪ •      Inspection- discoloration (greater risk for bruising), edema,

color (pallor- look at mucous membranes), uremia (yellow skin

color)

▪ •      Auscultation – lungs crackles, S3 in heart, listen for renal bruit

abnormal blood flow b/c renal artery stenosis esp. HTN pt (high

sound so listen with diaphragm on midclavicular line around

belly button);

▪ •      Palpation- kidneys can be palpable but its advanced practice;

▪ •      Percussion- check for inflammation of kidney, rule out CVA

tenderness;

▪ •      Assessment of the urethra – visual, look for blood, mucus or

pus

-          BODY WT for fluid balance!!!!!

Urinalysis

▪ •      Color, odor, and turbidity – can be very dilute or concentrated

▪ •      Specific gravity varies w/ hydration

▪ •      pH

▪ •      Glucose **

▪ •      Ketone bodies **

▪ •      Protein ** (look at glomerulus)

▪ •      Leukoesterase ** (UTI)

Nitrates** UTI

▪ •      Cells, casts, crystals, and bacteria ** (don’t worry about these

as much)

Normal urine shouldn’t have the ***

-          WBC 18,000 orders urine for Culture: Clean Catch urine sample: clean

front to back, void, catch; from Foley, clamp for while to build up urine,

cleanse port, attach syringe to aspirate urine.

-          24 Hour urine is a direct reflection of glomeruler filtration;

Blood Tests

▪ •      Serum creatinine – Renal is only thing that would make this

high;

▪ o   Normal value is 0.8-1.5;

▪ §  # is as important as trend, normal it should stay same, if it

alters then something is wrong in kidneys

▪ •      Blood urea nitrogen- Tells about protein metabolism: Renal,

hydration, GI, dietary protein intake

▪ o   State of hydration affects BUN; (Dehydration can elevate BUN)

▪ o    May indicate GI bleeding (Elevate BUN)

▪ •      Ratio of blood urea nitrogen to serum creatinine ~ 10:1

-GFR Rate: Greater than 65 normal.  Should be around 120;

- 24 hours for creatinine clearance: How many mL of blood should have

creatinine filtered off; it should be 120 mL; get big 3L jug with preservative so

the metabolic activity stops when you put uine in there so put it on ice; tell pt

to empty bladder (if they cant go make sure they tell you next time) If she

empties at 10 don’t collect that first sample but start then and collect all

urine after emptying collected;  You must start over if for some reason you

miss one void, or if there is contamination of sample (poop); If not in hospital

keep ice in cooler, use Foleys only if absolutely necessary;

- 24 hr direct reflection of GFR: if normal is 120 but report is 40, GF is

impaired. This tells you they have 30% fx left, if they cant filter serum levels

of electrolytes and things go up & Substances stay in blood (K+ cardiac

problems) 

- If filtration is significantly impaired, meds will stay in body; STORY: dr.

orders digoxin (increase contractility ad CO, before hand ou must check HR

b/c this slows HR… used for tachycardia and atrial arrhythmia… visal defects

(halos) indicate dig tox, seeing yellow lights, N/V) If creatinine clearance is

30mL/min tell dr he may want to decrease dose bc this is high value (not

filtering well)

Other Urine Tests

▪ •      Creatinine clearance—best indication of overall kidney

function norm ~ 120 ml/min

l Nursing Implications 24 hr urine (described above), bucket and ice

▪ •      Urine electrolytes – Usually nephrologist consulted bc they

aren’t making enough urine

▪ •      Urine drug screens – observe pt void then you directly take to

lab (chain of command)

▪ •      Serum Osmolarity - Urine and plasma ( plasma norm ~290) &

urine osmolarity 

Have pt empty bladder,  start at that time and go to the other 24hr container;

If filtration is reduced to 30% of normal; Substances are staying in the blood..

medications will stay in body, etc.  Digoxin – check hr, it increases

contractiility and output;  Give digoxin to control a irregular rhythm;  (Digoxin

toxic – see visual halos, n/v, yellow lights); 

Question: What to do first, Laxic or collect sample of urine?  Sample of urine

b/c a lasix increases urine output by blocking reabsorption of sodium;

Urine Culture

Front back cleaning, etc. look over clean catch; remember to stop the

drainage (DON’T GET SAMPLE FROM BAG) clamp Foley to build it up then take

it from the port after CLEANSING;

Other Diagnostic Tests

▪ •      Bedside sonography/bladder scanners – want to know how

much urine is in bladder; looking for post void residual usually;

not invasive or painful;

▪ •      Computed tomography (CT scan) – doesn’t matter if fecal is

there b/c it slices and can get the picture.  VERY SHORT, 5-10

min.  Looks like a doughnut table that goes through the hole,

(hold your breath now breathe) usually they need to inject

contrast dye (dye is nephrotoxic- ask if they are allergic to

iodine or shellfish (shrimp lobsters, etc), if the pt was allergic

then the Dr. would order a antihistamine and a steroid and

epinephrine should be on hand just in case things got out of

hand. Metformin + contrast dye = renal failure, so STOP the

metformin 48hr before and after the test, make sure you get

some other diabetic med like insulin; Muco-Mist given orally

48hr before and after contrast medium may protect kidneys,

this med is also a mucolytic which loosens pulmonary

secretions and is the antidote for acetaminophen;

▪ •      Kidney, ureter, and bladder x-rays (KUB) (come in to ER

abdominal x-ray must have bowel preparation to be helpful)

▪ •      Renal Ultrasound – noninvasive, quick, painless, need fluids so

NPO isn’t necessary,  looks at the structures, NO DYE!

▪ •      Intravenous pyelography (IVP) iv injection of contrast medium

but with x-ray no CT; If bowel is full same as KUB must do NPO,

bowel prep, allergy, nephrotoxicity;

l Bowel preparation

l Allergy information

l Fluids

 

Urodynamic Studies

▪ •      Studies that examine the process of voiding include:

l Cystometrography – how strong is urinary stream

l Urethral pressure profile

l Electromyography

l Urine stream test

Cystography and Cystourethrography-

Instilling dye into bladder via urethral catheter

▪ •      Monitoring for infection

▪ •      Encouraging fluid intake

▪ •      Monitoring for changes in urine output and for development

of infection from catheter placement

Retrograde Procedures

▪ •      Retrograde procedures go against the normal flow of urine.

▪ •      Procedure identifies obstruction or structural abnormalities

with the instillation of dye into lower urinary tract.

▪ •      Monitor for infection. High risk than normal;

▪ •      Follow-up care is the same as for a cystoscopic examination.

Dye not absorbed it’s a topical, not nephrotoxic;

Cystoscopy/Cystourethroscopy=“Cysto” see all way up ureters

l Procedure is invasive.

l Consent is required.

l Postprocedure care includes monitoring for airway patency, vital

signs, and urine output.

l Monitor for bleeding and infection.

l Encourage client to take oral fluids.

▪ •      Conscious sedations – morphine, fintanyl, versaid – quick

onset, short acting! Need a driver they can’t drive themselves

home; Invasive and inserting larger than typical cath, size 26

usually) – quick onset, short acting but leave loopy- risk for

FALLS;

Renal Arteriography (Angiography)-injection of dye in renal artery to show

blood flow into kidney

▪ •      Possible bowel preparation;

▪ •      Light meal evening before, then NPO

▪ •      Injection of radiopaque dye into renal arteries, √ allergies

▪ •      Assessment for bleeding

▪ •      Monitoring of vital signs

▪ •      FLUIDS

▪ •      Absolute bedrest for 4 to 6 hours

▪ •      Serum creatinine may be measured for several days to assess

effects of test/dye

▪ Remember all the allergies, etc. 

▪ Large cath inserted in femoral artery and gone up the renal artery inject

dye, check for hemmorage (big cath in big artery) First when pt back

do vital signs and check insertion site and palpate site blood will go

back; Hr will increase and bp decrease with pallor, weak pulse –

HEMMORAHGE;  if pt is bleed & surrounding tissue is hard –

indurations; Interventions to prevent bleeding pt must remain at bed

rest supine with leg straight hob elevated not more than 30degrees; 

force fluids, etc.;

▪ Question: An expected outcome for the pt who has undergone a renal

arteriogram is

A) maintaining bedrest for 12 hr

B) Maintaining the leg in a straight position for 12 hours

C) Discouraging ankle flexing and wt shifting  

D) measuring serum creatinine for several days

Answer: D

When creatinine gets around a 7 creatinine they are exhibiting uremia

symptoms;  Diaylsis is usually instituted around this time (Pt could have a 3

creatinine but could still need dialysis due to other factors like electrolytes)

-          *** (STORYTIME) Compartmental syndrome – (upper arms in football

players) swelling in tissue (impairs arterial circulation, below arm impaired,

death of muscle protein finally, dead muscle releases rhabdomyolysis, this

rhabdo causes renal failure, so those football players were at risk for ARF; ;;;

89 yr old brother caregiver for 91 yr old sister, 89yr old put sis to bed buddle

up and put her to bed but he feel and remained in floor overnight eventually

found but since it was winter with no heat he laid in a cold environment for a

long amount of time and he became hypothermic severe rhadomyolsis,

etc.;;;;

Renography

▪ •      Small amount of radioactive material, a radionuclide, used;

not radioactive, no safe precautions needed;

▪ •      Procedure via intravenous infection

▪ •      Follow-up care:

l Small amount of radioactive material may be excreted = force

fluids

l Maintain standard precautions.

l Client should avoid changing posture rapidly and avoid falling.

5 P’s Pain, Pulse Pallor, Paresthesia, Paralysis (Look at pictures on

Blackboard)

Percutaneous Renal Biopsy

•      Clotting studies

•      Preprocedure care

•      Follow-up care

l Assessment for bleeding for 24 hours

l Strict bedrest

l Monitoring for hematuria

Increase Comfort measures after procedure

Insertion of long needle thru skin (back) and poke and pull out a piece of

tissue (bleeding is a complication) place pt on back or sandback to put

pressure on kidney biopsy; vitals to assess for hemorrhaging; strict bedrest,

watch urine for blood b/c if so the kidney is bleeding;

Question: A priority assessment of a pt who had kidney biopsy include:

A) assess for compliance w/ strict bedrest

B) assess for signs of hypovolemia

C) Monitor for hematuria

 D) assess for pain;

                Answer: B; at risk for bleeding ad hemorrhage

E. coli: medicine for that is gentamycin but this is nephrotoxic and ototoxic;

ARF- SUDDEN ONSET, reversible,   ESRD/HD end stage renal disease; 

Question: A pt w/ ESKD has serum lab analysis: K+ 5.9 mEq/L, Na+ 152

mEq/L, creatinine 6.2mg/dL, BUN 60 mg/dL. A priority intervention would be:

A) Assess heart rate and rhythm. 

B) Contact the Dr

C) Prepare the pt for dialysis therapy

 D) Evaluate pt resp stat E) Weigh Pt

Answer: A: Potassium is very high!!

K+ is the most lethal problem with the labs so check cardiac.

Interventions for Clients with Acute & Chronic Renal Failure  Chapter

71

Acute Renal Failure= ARF SUDDEN ONSET!!!

•    Pathophysiology- rapid decline in function

•    Types of acute renal failure include:

–  Prerenal (cause = decreased perfusion)

–  Intrarenal =Intrinsic = ATN (cause = meds, bacteria, NSAIDs, &

pre/post renal)

–  Postrenal (cause = obstruction to urine flow)

30 urine per hr if not red flags should be up that something is wrong with

renal

Intervention: bolus with fluids; diuretic; dopamine to improve blood flow;

acute tubular necrosis –

Phases of ARF

•    Phases include:

–  Onset – precipitating event (First thing lost by kidney is lost to

concentrate urine);

–  Diuretic (non-oliguirc) non-oliguirc is that they are excreting water

just not the metabolic wastes

–  Oliguric /anuria Less than 30ml hour/no urine;  RISK FOR FLUID

OVERLOAD, hyperkalemia (no more OJ); Kayexlate orally or rectally –

it’s a Na, high sodium on one side and Potassium goes into Gut

which is good but we don’t want that much Sodium in body so we

mix it with a hypoosmolar that’s a sugar to even it out because

water will be pulled in and sodium will follow, pt K+ will go down

and the pt will poop a lot;  Insulin pushes sugar in the cell and K

goes with the sugar so by giving insulin potassium will follow, give

reg insulin IV if you do this an the pt does not need insulin with their

sugar level you can give 50% dextrose with it;

–  Recovery

•    Acute syndrome may be reversible with prompt intervention.

Assessment

•    History – precipitating event

•    Clinical manifestations- depends on phase/type (could be

hypo/hypervolemia); Increasing K, P, Mg and decreasing Ca & GFR

•       Laboratory assessment ↑Creatinine, BUN, K+, Phos, Mg++; ↓Cr

Clearance, Ca++

•    Radiographic assessment

•    Other diagnostic assessments such as renal biopsy

Interventions:

•    Prerenal

–  Fluid bolus

–  Diuretics

•    Intrinsic=Intrarenal

–  Low dose Dopamine (~3 mcg/kg/min)

–  Monitor fluid volume status

–  Calcium Channel Blockers (improve renal blood flow)

–  Monitor for medication toxicities; dose adjustments

•    Postrenal

–  Remove/bypass obstruction to urine flow

Medication Considerations

•    Cardioglycides = digoxin toxicity = ↓ dose

•    Vitamins and minerals-may need B9 & iron – boost all the blood

•    Biologic response modifiers= Epogen (Erythropoietin)

•    Phosphate binders= Amphojel to ↓ phos absorption, TUMS to

↑Ca++

•    Stool softeners and laxatives

•    Diuretics

•    Calcium channel blockers & HBP control; dilate renal artery;

DON’T TAKE ANYTHING WITH OTHER STUFF IN IT!! Fleets phosphate

or milk mag, etc, they cant excrete these; 

K+ management

Treatment

•    Diet therapy

–  Protein intake – according to client needs

–  Watch foods high/low in electrolytes of concern

–  Watch fluid intake

–  If elemental or TPN needed – special Renal Formula

 

•    Dialysis therapies

–  If needed for fluid, electrolyte, azotemia control

–  Hemodialysis

–  Peritoneal dialysis

–  ‘Continuous Renal Replacement Therapy’ (for fluid overload)

Posthospital Care

•    If renal failure is resolving, follow-up care may be required.

•    There may be permanent renal damage and the need for chronic

dialysis or even transplantation.

•    Temporary dialysis is appropriate for some clients.

•    May take ~ 1 year to resolve

 

Chronic Renal Insufficiency          Failure            ESRD         

•    Progressive, irreversible kidney injury;  kidney function does not

recover

Changes in Chronic Renal Failure → ESRD

•   Metabolic – azotemia -> uremia – causes HTN, creatinine is a

irritant (infects mucous membranes and linings of all organs) the <3

has the worst effect;

–  Urea and creatinine  (around 7)

•   Electrolytes

–   Sodium  (hyponatremia/hypernatremia)          

–   Potassium (hyperkalemia)

•   Acid-base balance

•   Metabolic acidosis

•   Calcium and phosphorus

•   Hyperphosphatemia/hypocalcemia

 

Clinical Manifestations

•    Neurologic: lethargy - coma

•    Cardiovascular: HBP, CHF, P E, dysrhythmias; “rub”; high

hyperlipidemia; uremic pericarditis

•    Respiratory: tachypnea, pleurisy

•    Hematologic: anemia, bruising; Low WBC & Platelets;

•    Gastrointestinal: bleeding, ulceration, hiccups, 

•    Urinary: decreased output

•    Skin: yellow/gray discoloration, pruritus, frost, ecchymoses

•    Sexuality: infertility, dryness, impotence

Proton pump inhibiter (protonix); lining should be resonance but if there is

fluid it will be dull;

Hemodialysis – there is a blood that flows to dialyzer, and the hemodialyzer

(where the filtering takes place);  Blood flows back to body;

Give heparin and get PTT’s done;

▪ If a heparin pt has dialysis and needs a thorascentis do the thora first

before the heparin; so give protamin sulfate to reverse the heparin; 

heparin stays active 6hr; if air or dialysate got in the airway it would

shut down;

Vascular Access

•    Arteriovenous fistula, or arteriovenous graft for long-term

permanent access

•    Hemodialysis catheter, dual or triple lumen, or arteriovenous

shunt for temporary access

•    Precautions: no restrictive clothing, tourniquets, NO   BP, IV, or

blood draw

•    Complications: clotting (= loss of access= no HD), infection

•    Listen for bruit, palpate for thrill; Assess any vascular assess

devices- listen for bruit, (sounds like a little air gun) 

Hemodialysis Nursing Care

•    Postdialysis care:

–  Monitor for complications such as hypotension, headache, nausea,

malaise, vomiting, dizziness, and muscle cramps (disequilibrium

syndrome).

–  Monitor vital signs and weight.

–  Avoid invasive procedures 4 to 6 hours after dialysis.

–  Continually monitor for hemorrhage.

–  Administer meds that were held prior to dialysis: HBP, dialyzable

antibiotics, digoxin, etc

There is an unequal another of creatinine in the CSF and serum (eventually

they will diffuse and be equal) BAD CSF problems.  SS above. 

HOLD MEDS PRIOR TO DIALYSIS OTHERWISE THEY WILL GO OUT!!

Peritoneal Dialysis

•    Procedure involves special catheter placed into the abdominal

cavity for infusion of dialysate.

•    Types of peritoneal dialysis:

–  Continuous ambulatory peritoneal

–  Automated peritoneal

–  Intermittent peritoneal

–  Continuous-cycle peritoneal

PD more closely mimics the kidney it just doesn’t make Vit D and

erythropoietin;

Complications            

•    Peritonitis

•    Pain

•    Exit site and tunnel infections

•    Poor dialysate flow

•    Dialysate leakage

•    Other complications

Nursing Care During Peritoneal Dialysis

•    Before treating: evaluate baseline vital signs, weight, and

laboratory tests.

•    Continually monitor the client for respiratory distress, pain, and

discomfort.

•    Monitor prescribed dwell time and initiate outflow.

•    Observe the outflow amount and pattern of fluid.

Complications of Hemodialysis

•    Dialysis disequilibrium syndrome

•    Infectious disease

•    Hepatitis B and C infections & HIV exposure—poses some risk for

clients undergoing dialysis & staff

Cost, time

Renal Transplantation

•    Candidate selection criteria

•    Donors

•    Preoperative care

•    Immunologic studies

•    Surgical team

•    Operative procedure

Postoperative Care

•    Urologic management

•    Assessment of urine output hourly for 48 hours.

•    Complications include:

– Rejection

•  S/S: increased  Temp, BP, pain, UO,  Cr/BUN,  weight

– Acute tubular necrosis

–  Thrombosis

–  Renal artery stenosis

–  Other complications

–  Immunosuppressive drug therapy

–Psychosocial preparation

Cystitis & Infections of Lower Urinary Tract (Chapter 69)

•    Inflammation of the bladder

Most commonly caused by bacteria (or viruses, fungi, or parasites ) from the

rectum/vagina moving into the external urethra to the bladder, ureter, &

even to the kidney (pyelonephritis)

E. Coli is the most common bacteria

Catheter related infections common during hospital stay

•    HIGH RISK: UROSEPSIS with high mortality

UTI – Urinary tract infection – inflammation of lower urinary system (FOLEY

CATH is highest in hospital) Women are more likely to get it because urethra

is shorter & Perneal area so close;  Men get it due to enlarged prostate b/c it

obstructs urine;  (Empty bladder q 3 hr) 

Cystitis – visible vessels, lots of tiny red dots, hemorrhagic area from

infection;

Most common sign is: FREQUENCY: PAIN (burning);

Incidence and Prevalence of Cystitis

•    2nd most common reason to visit to HCP

•    ASSESSMENT

–   Frequent urge to urinate

–   Dysuria

–   Urgency

•    UA needed to test for leukocyte esterase (+ in UTI), also WBCs,

RBCs (WBC URINE CLOUDLY)  (SMOKY or pink/red if RBC in urine) 

For older adults in the hospital, the 1st sign is altered mental status. 

Type of organism confirmed by urine culture

↑serum WBCs with ↑ in ‘bands’ (adolescent WBC)

      When we are faced with an infection bone marrow will release adolescent

aged WBC to help the “tired already in circulation” WBC; should not have

these “bands” unless we are sick; LOOK AT TYPE OF WBC (are they in

the correct proportion) Bandemia

      E. coli is the most common type of bacteria found as a cause of

UTI;

CYSTO to R/O abnormalities

Pharmacological Therapy

•Urinary antiseptics: Macrobid, Macrodantin (nitrofurodantin); Pt will frequent

recurring UTI may have a low dose daily; this decreases bacteria growth

•Antibiotics: Septra, Cipro, Levaquin, Amoxil, Duricef

•Analgesics: Pyridium (overcounter med) Orange color urine; will diminish

burning but doesn’t address cause; drink LOTS of liquids;

•Antispasmodics: Anaspaz (b/c the bladder is irritated so it needs something

to diminish the spasm)

•Antimicrobials: Bactrim/Septra, Cipro/Levaquin, Amoxil, Duricef

•Antifungal agents: Nizoral

Long-term antibiotic therapy for chronic, recurring infections

•Intravaginal Estrogen for postmenopausal women (general dryness as

women age) cream or tablets

QUESTION: What is an expected outcome for the older adult male pt

with a history of asthma who is being treated w/ nitrofurntin

(Macrobid)?

A.    Orange-colored urine

B.     Constipation

C.     Blurred vision

D.    Flu-like symptoms;

Answer: D - monitor these symptoms in older pt taking

nitrofurantoin and those with pulmonary disease;   

Nonpharmacological Management

•    Urinary elimination after sex & before bedtime

Urinate q 3-4hr                                                

•    Diet therapy:  all food groups, ↑ calorie RT ↑ increase in

metabolism caused by the infection; ↑ intake 2-3 L/day of fluids,

possible intake of cranberry juice; d/c caffeine; Vit C foods/fluids

•Other pain relief measures, such as warm sitz baths but not

vigorous cleaning of perineum or douching

• Cotton undies/no tight jeans

•Daily perineal cleansing (but not vigorous cleaning, douching or bubble

baths) 

Question: 21 yr old male complaining of burning and difficulty with

urination.  Priority question in obtaining info about pt chief complaint would

be:

1.How long have you had these symptoms?

2.Do you have low back pain?

3.Are you sexually active? 

4.Have you had fever in past 24 hr

Answer: C  Most common cause of urethritis in men is STD: Ureaplasma,

Chlamydia or Trichomonas vaginalis!!

Can lead to pylenephritis & Urosepsis ; Altered mental status

(decreased blood flow to brain)

 

Urinary Incontinence

•    Impacts > 13 million in USA. Mostly ♀

•    Not a normal result of aging, but does ↑ with age

•    Five types of incontinence include:

–   Stress – little when coughing, sneezing, vomiting; 

–   Urge – Cant make it to the bathroom

–   Mixed

–   Overflow – spinal cord injury, bladder wont empty and it starts to

leak

–   Functional (cognitive impairment) Don’t know when to recognize

when its time (Dementia, unresponsive individual)

The brain sends nerve signals telling muscles to hold urine or let it out. 

Nerves send signals to the brain.  Signals tell when the bladder is full or

empty.  

Collaborative Management

•    Assessment: thorough client history (make sure not constipated)

•    Clinical exam to R/O cystocele (herniation of bladder into

vagina), rectocele, prolapsed uterus & assess perineal sensation;

medication history

•    Urinalysis: R/O infection

•    Radiographic assessment & other diagnostic assessments to

determine urinary system health

(Lightly touch anus, contract when it touch, if it doesn’t contract then they

may have nerve root problem to bladder)

•    Interventions include:

–   Keeping a diary

–   Behavioral interventions

–   Diet modification: weight loss, no caffeine, alcohol

–   Pelvic floor exercises (Kegels)

–   Drug therapy: Estrogen, Pro-Banthine, Ditropan, Detrol (increase

intraocular Pressure) see eye dr. can cause glaucoma; Trofranil-

Antianxiety and has anticolingeric; all these meds cause DRY

MOUTH,

 

URINARY RETENTION

–   Vaginal cone weights

–   Urinary habit training (freq basis)

–   Intermittent self-catheterization (clean technique)

–   Containment of urine and protection of the client’s skin

–   Applied devices: penile clamp, pessaries (object place inside

vagina that cystisilfallen bladder, take out clean etc), condom

Last resort: Urinary catheterization

Surgical Management

•    Preoperative care (Abdominal surgical procedure)

•    Operative procedure: see list pg 1692 (1. Inject collagen which

works 50% of the time. 2. Surgery to pull bladder back to be

surgically correct (bladder tack-up) 3. Suprapublic cath)

•    Postoperative care (Airway #1, at risk for pneumonia b/c they

won’t want to deep breath due to pain; Circulation: DVT (calf pain

edema & pulmonary embolism is main concern which pt has chest

pain SOB and alter gas exchange)

–   Assess for and intervene to prevent or detect complications.

–   Secure urethral or suprapubic catheter.

–   No sex until post-op check (~6 wk) to allow good healing

–   No heavy lifting for 3 months (5lbs)

–   No exercise such as running, aerobics, stair-climbers until

completely healed

Any pelvic surgery puts them at higher risk for DVT (ambulation,

antiembolism stockins, etc.)

Urolithiasis

•    Presence of calculi (stones) in the urinary tract

•    History of urologic stones

•    Clinical manifestations ---- EXTREME pain when stone moves

NCLEX says pain is a psychological diagnosis so if this appears, it’s most

likely not the number 1 choice.

•    Laboratory assessment: -- UA, ↑WBC if infection

•    Radiographic assessment:  CT of abdomen, (IVP)

Pain when stone actually moving; (pain location depends, if stone in pelvis is

in back, upper ureter in upper side and when it starts moving down it starts

moving toward the bladder) 25 yr old female pain in right lower abdomen

(ectopic preg, appendicitis, ovaries problems) Have pt go for cat scan b/c the

IVP (needs bowel prep) will not be bowel prep;

Stones make WBC go up just like infection does; 

Question:  A pt with urolithiasis has not voided in 7 hr.  What is primary

concern for this pt?

1.Hematuria

2.Hydronephrosis (water on nephron);

3.Infection

4.Pain

Risk for blockage; risk for infection (physiology) Pain; 

Answer: B - A primary concern is prolonged obstruction.  As the blockage

persists, hydronephrosis and permanent kidney damage may develop.  Other

concerns with urolithiasis include infection, hematuria, and effective tx of pt

pain

Interventions

•    Drug therapy often with Opioid analgesics (morphine) IV; Watch

for resp distress; constipation

•    Nonsteroidal anti-inflammatory drugs

•    Pain medications at regular intervals

•    Constant delivery system

•    Spasmolytic drugs (Ditropan & Pro-Banthine)—important for

relief of pain

•    Complementary and alternative therapy

Anticipate pt to be on increase Fluids (rates greater than typical amt) Watch

for fluid vol overload; get a filter or strainer; Pt probably nausea  and

probably on an antibiotic to prevent infection;

Lithotripsy

•    Extracorporeal shock wave lithotripsy uses sound, laser, or dry

shock wave energy to break the stone into small fragments. (Sound

waves used outside of body to crush stones so that they can move)

sore abdomen with bruising, hematuria; tell pt to ice the abdomen

etc

•    Client undergoes conscious sedation

•    Topical anesthetic cream is applied to skin site of stone.

•    Continuous monitoring is by electrocardiography

Surgical Management (Cysto – scope thru bladder up ureters and

using implement with a loop try to get above stone and scoop it

down) expect pain, hematuria, inflammation;

•    Minimally invasive surgical procedures

•    Stenting; after scraping there will be a stent (small tube) to keep

ureter open until inflammatory response stops; there may be string

out peepee hole :] make sure pt don’t put out string b/c that will

remove stent; (week to ten days inflammation)

•    Retrograde ureteroscopy

•    Percutaneous ureterolithotomy and nephrolithotomy

•    Open surgical procedures

–   Preoperative care

–   Operative procedure

Postoperative Care

•    Routine postoperative care procedures for assessment of

bleeding, urine, and adequate fluid intake

•    Strained urine

•    Infection prevention

•    Drug therapy

•    Diet therapy

•    Prevention of obstruction

Drug Therapy

•    Drug selection to prevent obstruction depends on what is

forming the stone:

–   Calcium; Low Ca diet, hydrodiurl promotes resorption of Ca into

blood

–   Oxalate; Low oxalate diet; zyloprim, vit B6

–   Uric acid; metabolic disease GOUT makes kidney stones, low

purine diet (low in proteins and greens) Med allopurinol often given,

also probencid

–   Cystine – hydration, alkalinazation, captopril

Urothelial Cancer – abnormal growth of abnormal cells

•    Collaborative management

•    Assessment

•    Diagnostic assessment

•    Nonsurgical management

–   Prophylactic immunotherapy

–   Chemotherapy

–   Radiation therapy

Prevention of Bladder Cancer- Protect self against inhaled chemicals; drink

lots of fluids & void freq; extra Vit A (protectant); NO MARIJUANA  or

cigarettes (its an irritant to bladder)

Tx of bladder cancer: Intravesical Chemotherapy  (medication instilled into

the bladder – intravesical – through a foley medicine get up there and the

foley will be clamped so medicine will get contact with bladder lining and

cancer (NPO, so it wont dilute the medicine) SAVE bladder, drug is not

absorbed and will not have side effects to rest of body;

Surgical Management – if cancer is stage 4 and taking bladder out is

a must;

•    Preoperative care

•    Operative procedures – preserve bladder if possible; if not ->

cystectomy & ileal conduit; ileal conduit, urostomy – take out

bladder and resect 6in of bowel and create tube (one end is closed

the other end is brought to skin –stoma – ureters are implanted into

the tube and urine will flow to the stoma constanly) this pt will be

incontinent – flowing of urine constantly (POUCH)

•    Postoperative care includes:

–   Collaboration with enterostomal (WOCN) therapist

–   Kock’s pouch or Indiana pouch – took segment of bowel and made

pouch and the connected tube and got a stoma – this pt is continent

– Advantage is that its continent; pt will cath pouch every 4 hrs, no

external pouch needed and learn sense of fullness (in right quad)

Disdvantage – special surgeon, longer surgery time,

–   Neobladder – make new bladder if ureters weren’t affected with

cancer, less common;

Nursing – assess skin around stoma, not red or inflamed; stoma pink, moist

(look like lining of mouth) Constant flow of urine;

 

Urostomy Stoma & Pouches

Nephrostomy- tube placed into pelvis of kidney, pouch system with stent

draining urine in pouch; high risk for infection; 

Question:  Pt with hydronephrosis she had nephrostomy tube placed. Which

assessment data requires immediate intervention and notification of Dr?

1.Hematuria

2.Cloudy Urine

3.Pt complaint of back pain  

4. Pot 4.9

Answer: C  if the amt of drainage decreases and the pt has back pain, the

nephrostomy tube may be clogged or dislodged.

Ureterostomy – bring ureters out to skin

Crystals:  Occur when urine is too alkaline. Can cause stomal irritation and or

bleeding. Urinary crystals can be prevented by keeping it clean;

Bladder Trauma

•    Causes may be due to injury to the lower abdomen or stabbing or

gunshot wounds.

•    Surgical intervention is required.

•    Fractures should be stabilized before bladder repair.

Frank blood – very red!!! NOT GOOD;;

 

Interventions for Clients with Renal Disorders   Chapter 74

Polycystic Kidney Disease

•      Inherited (autosomal dominant) disorder in which fluid-filled

cysts develop in the nephrons – 50% chance of getting it;

•      Key features include:  Causes cysts to form in the kidney

–  Abdominal or flank pain (swelling of kidney) – diminished blood

flow releasing renin

–  Hypertension from release of renin

–  Nocturia can’t concentrate urine

–  Increased abdominal girth from swelling of kidney

NO CURE!!

Prevent complication

Genetic Testing

KIDNEY TRANSPLANT!!!!

PKD DIAGNOSIS

Ultrasound

CT

MRI

Genetic history

Urinalysis (protein & blood)

Decreased kidney function

Interventions

•      Pain management- caution NSAIDs

•      Bowel management- constipation from enlarged kidneys

•      Medication management - ACE inhibitors & other HBP meds

•      Energy management

•      Fluid monitoring – low Na+ diet

•      Urinary retention care – Credé –emptying bladder by manually

pushing or pulling butt hairs (may have incontinence)

•      Infection protection

Question:  A possible outcome for the pt being treated with spironolactone for

nephritic syndrome is the development of

A)      Hyponatremia

B)      Hyperkalemia

C)      Hypercalcemia

D)     Hypophosphatemia

Answer B

 

Pyelonephritis (chapter 74)

•      Bacterial infection in the kidney (upper urinary tract)

•      Key features include:

–  Fever, chills, tachycardia, and tachypnea

–  Flank, back, or loin pain

–  Abdominal discomfort

–  Turning, nausea and vomiting, urgency, frequency, nocturia

–  General malaise or fatigue

•      Hypertension

•      Inability to conserve sodium

•      Decreased concentrating ability

•      Tendency to develop hyperkalemia and acidosis

More likely in females!!

Acute Pain Interventions

•      Pain management interventions

•      Drug therapy

–  Antibiotics

–  Urinary antiseptics (macrodantin)

•      Diet therapy

–  Force fluids

Surgical Management – for structural problems

•      Preoperative care

–  Antibiotics

–  Client education

•      Operative procedure: pyelolithotomy, nephrectomy, ureteral

diversion, ureter reimplantaton

•      Postoperative care for urologic surgery

Glomerulonephritis= Nephritic Syndrome

•      Assessment ~ 10 days after infection usually Streptococcus

(resulting in antibody/antigen reactions within glomerulus);  edema

(if protein not in vessel water leaks into interstial), proteinuria,

hematuria HBP, fatigue, ↓GFR,↑BUN/Cr, + Strep titers

•      Management of infection

•      Prevention of complications

–  Diuretics

–  Sodium, water, potassium, and protein restrictions

–  Dialysis, plasmapheresis

–  Client education

Chronic Glomerulonephritis --  Results in loss of nephrons leading to

↓GFR → renal failure

Question: Male pt complains of progressive fatigue, anorexia, wt gain and

dysuria with dark colored urine what is the priority nursing care?

1.Do you have family hx of renal disease

2.Have you had recent infection

3.Do you experience freq UTI

4.When did you first notice symptoms

Answers: B   :  The onset of symptoms is 10 days from time of infection. 

Systemic strept infection is more common in men as precursor infection of

acute glomerulonephritis

Nephrotic Syndrome

•      Condition of increased glomerular permeability that allows

larger protein molecules to pass through the membrane into the

urine and be removed from the blood

•      Severe loss of protein into the urine; larger molecules

Proteinuria; lots of bubbles in toilet; plum (periorbital edema) sclera edema;

chest for pulmonary edema;  (AIR IS BLACK ON CHEST X-RAY); STREP

•      Treatment involves:

–  Immunosuppressive agents (Reverse/Protective Isolation –

neutropenic) Wear mask, gloves, gown AT RISK FOR INFECTION

–  Angiotensin-converting enzyme inhibitors

–  Heparin

–  Diet changes

Rest!

-          Mild diuretics

Question: The older adult pt with acute glomerulonephritis is often

misdiagnosed with

1.CVA

2.Transient ischemic attack

3.Aortic aneyrysm

4.CHF

Answers: D

Renal Trauma

•      Minor injuries such as contusions, small lacerations

•      Major injuries such as lacerations to the cortex, medulla, or

branches of the renal artery

•      Collaborative management

•      Nonsurgical management: drug therapy and fluid therapy

•      Surgical management: nephrectomy or partial nephrectomy

BLEEDING major problem if there is trauma; prep for blood transfusion,

surgery, etc.  Don’t want to overstress kidneys after this kind of accident!

 

Renal Cancer

Stage 1 7cm; Stage II 7Cm; Stage III Gerota’s fascia; Stage IV other organs

and lympg nodes

Cancer is abnormal growth of abnormal cells; SPREAD to other body organs

(the spread to the lung, etc. is usually when manifestation starts;  Cure rate

for renal cancer is not really high; difficult to treat b/c we don’t find the

disease early;

Tx: Remove diseased kidney f (long incision from diaphragm to center of

abdomen and all around sides; Have to spread all those kidneys;  PT coming

straight from surgery #1 priority is AIRWAY, BREATHING, CIRCULATION

(watch for hemorrhage, vitals, pulse quality, skin color, output from drain, 

the hr after pt comes back should be sangious, 48hr after it should be sero-

sang, BUN and creatinine should stay normal; Pain should be the next

concern;

Nephrectomy: Traditional vs  Laproscopic 

Lapro: less heal time, not as painful, smaller scars;  (CO2) - absorbed by body, shoulder pain; RISK for bleeding b/c they can’t see.