Assessing Clients with Urinary System Disorders

I. Background of Anatomy and Physiology A. Kidneys 1. Outside of peritoneal cavity on either side of vertebral column at levels of T12 L3 2. Supported by 3 layers of connective tissue a. Outer renal fascia: surrounds kidney and adrenal gland b. Middle adipose capsule: cushions and holds kidney in place c. Inner renal capsule: barrier against infection; protects kidneys from trauma 3. Functions a. Balance solute and water transport b. Excrete metabolic waste products c. Conserve nutrients d. Regulate acid-base balance e. Secrete hormones to help regulate blood pressure, erythrocyte production, calcium metabolism f. Form urine 4. Internal regions of each kidney a. Cortex: outer region; contains glomeruli b. Medulla: contains renal pyramids (formed from bundles of collecting tubules); renal columns (extensions of cortex) c. Pelvis: innermost region continuous with ureter as leaves hilum 1. Major and minor calyces, branches of pelvis, extend toward medulla and collect urine and empty into pelvis 2. Urine channeled through ureter into bladder for storage 3. Wall of calyces, renal pelvis, and ureter contain smooth muscle and move urine by peristalsis 5. Each kidney contain about 1 million nephrons a. Nephron: contains tuft of capillaries called glomerulus, which is surrounded by glomerular capsule (Bowmans space) b. Renal corpuscle: glomerulus and capsule c. Endothelium of capillaries of glomerulus are very porous d. Solute-rich fluid (filtrate) pass from capillaries into capsule; then channeled into Proximal Convoluted Tubule (PCT) of nephron e. Peritubular capillaries reabsorb substances into plasma from filtrate 1. Active transport: glucose, sodium, potassium, amino acids, proteins, vitamins 2. Passive transport: 70% water, chloride, bicarbonate f. Filtrate moves into loop of Henle and is concentrated g. Filtrate moves to Distal Convoluted Tubule (DCT) where solutes are secreted into filtrate h. Collecting duct receives newly formed urine from many nephrons and channels urine through calyces of renal pelvis into ureter B. Ureters 1. Bilateral tubes 10 12 inches long (25 30 cm) 2. Transport urine from kidney to bladder through peristalsis 3. Wall of ureter has 3 layers a. Inner is epithelial mucosa b. Middle is smooth muscle c. Outer is fibrous connective tissue C. Urinary Bladder 1. Posterior to symphysis pubis a. Males: immediately in front of rectum b. Females: next to vagina and uterus 2. Storage of urine 3. Trigone is smooth triangular portion of base of bladder outlined by openings for ureters and urethra 4. Layers a. Epithelial mucosa lining (Internal) b. Connective tissue submucosa c. Smooth muscle layer: detrusor muscle made up of fibers arranged to allow bladder to expand or contract according to amount of urine in it d. Fibous outer layer 5. Size of healthy adults holds 300 500 ml before internal pressure rises and signals need to empty 6. Sphincters a. Internal: relaxes in response to full bladder and signals need to urinate b. External: formed by skeletal muscle, under voluntary control D. Urethra 1. Thin-walled muscular tube that channels urine to outside of body 2. Extends from base of bladder to external urinary meatus a. Males: 8 inches long (20 cm) channels for semen and urine; Protstate gland encircles urethra at base of bladder; urinary meatus located at end of the glans penis b. Females: 1.5 inches long (3 -5 cm) anterior to vaginal orifice E. Formation of Urine 1. Kidneys process 180 liters (47 gallons) of blood-derived fluid each day; 1% excreted as urine; rest is returned to circulation 2. Done by nephron through 3 processes: a. Glomerular filtration b. Tubular reabsorption c. Tubular secretion

Glomerular filtration 1. Definition: passive, nonselective process in which hydrostatic pressure forces fluid and solutes through a membrane 2. Glomerular filtration fate (GFR): amount of fluid filtered from blood into capsule per minute 3. GFR is influenced by 3 factors a. Total surface area available for filtration b. Permeability of filtration membrane c. Net filtration pressure (proportional to GFR) 4. Net filtration pressure responsible for formation of filtrate 5. Net filtration pressure determined by 2 forces a. Hydrostatic pressure (push) b. Osmotic pressure (pull) 6. Normal GFR in both kidneys is 120 125 ml/min in adults; held constant under normal conditions by a. Renal autoregulation: Diameter of afferent arterioles responds to pressure changes in renal blood vessels: 1. Increase in systemic blood pressure: renal vessels constrict 2. Decline in blood pressure: afferent arterioles dilate b. Renin-angiotensin mechanism 1. Juxtaglomerular apparatus located in distal tubules respond to slow filtrate flow by releasing chemical that cause intense vasodilation of afferent arterioles 2. Increase in flow of filtrate promotes vasoconstriction, decreasing GFR 3. Drop in systemic blood pressure triggers juxtaglomerular cells to release renin; acts on angiotensinogen to release angiotensin I which is converted to angiotensin II causing systemic vaso-constriction and causes systemic blood pressure to rise c. Extrinsic control through sympathetic nervous system 1. Under extreme stress causes strong constriction of afferent arterioles and inhibits filtrate formation 2. Causes release of renin, increasing systemic blood pressure G. Tubular reabsorption: Proximal tubules constantly regulate and adjust rate and degree of water and solute reabsorption according to hormonal signals H. Tubular secretion 1. Substances (hydrogen and potassium ions, creatinine, ammonia, organic acids) move from blood into tubules as filtrate 2. Mechanism for disposal of substance such as medications 3. Rids body of undesirable substances that had been reabsorbed and rids body of excess potassium ions (regulation of pH) I. Normal Composition and Volume of Urine 1. Result of countercurrent exchange of fluid through tubes of loop of Henle and vasa recta (tiny capillaries) 2. Dilution or concentration of urine largely determined by action of antidiuretic hormone (ADH) 3. Urine by volume is 95% water; 5% solutes; most of weight from urea J. Clearance of waste products 1. Renal plasma clearance: ability of kidney to clear a given amount of plasma of particular substance in a given time 2. Waste products cleared by kidneys a. Urea: nitrogenous waste product from breakdown of amino acids by liver; 25 30 gram daily b. Creatinine: end product of creatine phosphate, found in skeletal muscle) c. Uric acid: metabolite of nucleic acid metabolism d. Ammonia e. Bacterial toxins f. Water-soluble drugs 3. Tests of renal clearance used to determine GFR and glomerular damage K. Renal hormones 1. Activation of Vitamin D: absorption of calcium and phosphate a. Vitamin D enters body though dietary intake of action of ultraviolet rays on cholesterol in skin b. Activated first in liver and then kidneys under stimulation by parathyroid hormone 2. Erythropoietin a. Produced by kidneys in response to decreased levels of oxygen to kidney b. Hormone stimulates bone marrow to produce red blood cells 3. Natriuretic hormone a. Released by right atrium of heart in response to increased volume and stretch b. Inhibits ADH secretion which makes collecting tubules less porous, producing large amount of dilute urine

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Assessment of Urinary System Function

A. Health assessment interview to collect subjective data 1. Obtain information about current urinary status including a. Urine: color, odor, amount b. Any difficulty starting stream c. Frequency or urgency in urinating d. Dysuria: painful urination e. Nocturia: excessive urination at night f. Hematuria: blood in the urine g. Oliguria: voiding small amounts of urine h. Polyuria: voiding large amounts of urine i. Presence of any discharge j. Presence of flank pain 2. For any problem identified a. Analyze onset b. Characteristics and course c. Severity d. Factors that precipitate or relieve problem e. Associated symptoms f. Timing and circumstances 3. Additional information regarding urinary status a. Hematuria 1. Determine use of medications 2. Presence of bleeding problems 3. In females, whether menstruating b. Pyuria (cloudy, foul-smelling urine) 1. Indicative of infection, determine whether client has temperature elevations, chills, malaise 2. In males, retrograde ejaculation c. Pain 1. Location, duration, intensity 2. Kidney pain: present in back and costovertebral angle and may spread toward umbilicus 3. Renal colic: severe, sharp, stabbing, excruciating in flank, bladder, urethra, testes, ovaries 4. Bladder and urethral pain: dull, continuous or spasmodic 5. Distended bladder: constant pain increased by any pressure over bladder 4. History: Family history of altered structure or function a. End-stage renal disease b. Renal calculi c. Frequent infections d. Hypertension e. Diabetes Mellitus 5. Life style, diet, work history a. Cigarette smoking b. Exposure to toxic chemicals c. Usual amount and type of fluid intake d. Usual voiding habits e. Self-care measures B. Physical assessment to collect objective data 1. Skin assessment with abnormal findings a. Pallor of skin and mucous membranes: anemia b. Decreased skin turgor: dehydration c. Edema: fluid volume excess d. Uremic frost (uric acid crystals): untreated renal failure 2. Abdominal assessment with abnormal findings a. Enlargement or asymmetry: hernia or superficial mass b. Prominent veins: renal dysfunction c. Distended, glistening, tight skin: fluid retention d. Fluid accumulation in peritoneal cavity: ascites 3. Urinary meatus assessment with abnormal findings a. Redness, swelling, discharge: infection or sexually transmitted disease b. Ulceration: sexually transmitted disease c. In males, deviation from midline of meatus: congenital defect 4. Kidney assessment with abnormal findings a. Systolic bruits: renal artery stenosis b. Tenderness and pain on percussion in costovertebral angle: glomerulonephritis or glomerulonephrosis c. Palpation of kidney 1. Mass or lump: tumor or cyst 2. Pain or tenderness: inflammatory process 3. Soft or sponginess: chronic renal failure 4. Bilaterally enlarged kidneys: polycystic kidney disease 5. Unequally sized kidneys: sign of hydronephrosis 5. Bladder assessment with abnormal findings a. Dull percussion tone over bladder after voiding: urinary retention b. Palpation of bladder as firm, rounded organ: distended bladder

Nursing Care of Clients with Urinary Tract Disorders

I. Client with a Urinary Tract Infection (UTI) A. Background 1. Bacterial infections of urinary tract are a very common reason to seek health services 2. Common in young females and uncommon in males under age 50 3. Common causative organisms a. Escherichia coli (gram-negative enteral bacteria) causes most community acquired infections b. Staphylococcus saprophyticus, gram-positive organism causes 10 15% c. Catheter-associated UTIs caused by gram-negative bacteria: Proteus, Klebsiella, Seratia, Pseudomonas 4. Normal mechanisms that maintain sterility of urine a. Adequate urine volume b. Free-flow from kidneys through urinary meatus c. Complete bladder emptying d. Normal acidity of urine e. Peristaltic activity of ureters and competent ureterovesical junction f. Increased intravesicular pressure preventing reflux g. In males, antibacterial effect of zinc in prostatic fluid B. Pathophysiology 1. Pathogens which have colonized urethra, vagina, or perineal area enter urinary tract by ascending mucous membranes of perineal area into lower urinary tract 2. Bacteria can ascend from bladder to infect the kidneys 3. Classifications of infections a. Lower urinary tract infections: urethritis, prostatitis, cystitis b. Upper urinary tract infection: pyelonephritis (inflammation of kidney and renal pelvis) C. Risk Factors 1. Aging a. Increased incidence of diabetes mellitus b. Increased risk of urinary stasis c. Impaired immune response 2. Females: short urethra, having sexual intercourse, use of contraceptives that alter normal bacteria flora of vagina and perineal tissues; with age increased incidence of cystocele, rectocele (incomplete emptying) 3. Males: prostatic hypertrophy, bacterial prostatitis, anal intercourse 4. Urinary tract obstruction: tumor or calculi, strictures 5. Impaired bladder innervation 6. Bowel incontinence 7. Diabetes mellitus 8. Instrumentation of urinary tract D. Cystitis 1. Most common UTI 2. Remains superficial, involving bladder mucosa, which becomes hyperemic and may hemorrhage 3. General manifestations of cystitis a. Dysuria b. Frequency and urgency c. Nocturia d. Urine has foul odor, cloudy (pyuria), bloody (hematuria) e. Suprapubic pain and tenderness 4. Older clients may present with different manifestations a. Nocturia, incontinence b. Confusion c. Behavioral changes d. Lethargy e. Anorexia f. Fever or hypothermia 5. Readily responds to treatment 6. Untreated, may involve kidneys 7. Severe or prolonged may cause sloughing of bladder mucosa with ulcer formation 8. Chronic cystitis may lead to bladder stone formation E. Catheter-Associated UTI 1. Longer a catheter is in place, greater risk for infection 2. Bacteria may enter catheter system at connection between catheter and drainage system or through emptying tube of drainage bag 3. UTIs may be asymptomatic 4. Most infections resolve with removal of catheter and short course of antibiotic 5. Most significant complication is gram-negative bacteremia F. Pyelonephritis 1. Inflammation of renal pelvis and parenchyma (functional kidney tissue) 2. Acute pyelonephritis a. Results from an infection that ascends to kidney from lower urinary tract b. Risk factors 1. Pregnancy 2. Urinary tract obstruction and congenital malformation 3. Urinary tract trauma, scarring 4. Renal calculi

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5. Polycystic or hypertensive renal disease 6. Chronic diseases, i.e. diabetes mellitus 7. Vesicourethral reflux c. Pathophysiology 1. Infection spreads from renal pelvis to renal cortex 2. Kidney grossly edematous; localized abscesses in cortex surface 3. E. Coli responsible organism for 85% of acute pyelonephritis; also Proteus, Klebisella d. Manifestations 1. Rapid onset with chills and fever 2. Malaise 3. Vomiting 4. Flank pain 5. Costovertebral tenderness 6. Urinary frequency, dysuria e. Manifestations in older adults 1. Change in behavior 2. Acute confusion 3. Incontinence 4. General deterioration in condition Chronic pyelonephritis a. Involves chronic inflammation and scarring of tubules and interstitial tissues of kidney b. Common cause of chronic renal failure c. May develop from chronic hypertension, vascular conditions, severe vesicourteteral reflux, obstruction of urinary tract d. Behaviors 1. Asymptomatic 2. Mild behaviors: urinary frequency, dysuria, flank pain Collaborative Care a. Eliminate causative agent b. Prevent relapse c. Correct contributing factors Diagnostic Tests a. Urinalysis: assess pyuria, bacteria, blood cells in urine; Bacterial count >100,000 /ml indicative of infection b. Rapid tests for bacteria in urine 1. Nitrite dipstick (turning pink = presence of bacteria) 2. Leukocyte esterase test (identifies WBC in urine) c. Gram stain of urine: identify by shape and characteristic (gram positive or negative); obtain by clean catch urine or catheterization d. Urine culture and sensitivity: identify infecting organism and most effective antibiotic; culture requires 24 72 hours for results; obtain by clean catch urine or catheterization e. WBC with differential: leukocytosis and increased number of neutraphils Diagnostic Tests for adults who have recurrent infections or persistent bacteriuria a. Intravenous pyelography (IVP) or excretory urography 1. Evaluates structure and excretory function of kidneys, ureters, bladder 2. Kidneys clear an intravenously injected contrast medium that outlines kidneys, ureters, bladder, and vesicoureteral reflux 3. Check for allergy to iodine, seafood, radiologic contrast medium, hold testing and notify physician or radiologist b. Voiding cystourethrography: instill contrast medium into bladder and use xray to assess bladder and urethra when filled and during voiding c. Cystoscopy 1. Direct visualization of urethra and bladder through cystoscope 2. Used for diagnostic, tissue biopsy, interventions 3. Client receives local or general anesthesia d. Manual pelvic or prostate examinations to assess structural changes of genitourinary tract, such as prostatic enlargement, cystocele, rectocele Medications a. Short-course therapy: 3 day course of antibiotics for uncomplicated lower urinary tract infection; (single dose associated with recurrent infection) b. 7 10 days course of treatment: for pyelonephritis, urinary tract abnormalities or stones, or history of previous infection with antibiotic-resistant infections; clients with severe illness may need hospitalization and intravenous antibiotics c. Antibiotics commonly used for short and longer course therapy include trimethoprimsulfamethoxazole (TMP-SMZ), or quinolone antibiotic such as ciprofloxacin (Cipro) d. Intravenous antibiotics used include ciprofloxacin, gentamycin, ceftriaxone (Rocephin), ampicillin e. Possible outcomes of treatment for UTI, determined by follow-up urinalysis and culture 1. Cure: no pathogens in urine 2. Unresolved bacteriuria: pathogens remain 3. Persistent bacteriuria or relapse: persistent source of infection causes repeated infection after initial cure 4. Reinfection: development of new infection with different pathogen f. Prophylactic antibiotic therapy with TMP-SMZ, TMP alone or nitrofurantoin (Furadantin, Nitrofan) may be used with clients who experience frequent symptomatic UTIs

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Catheter-associated UTI: removal of indwelling catheter followed by 10 14 day course of antibiotic therapy

Surgery a. Surgical removal of large calculus from renal pelvis or cystoscopic removal of bladder calculi which serve as irritant and source of bacterial colonization; may also use percutaneous ultrasonic pyelolithotomy or extracorporeal shock wave lithotripsy (ESWL) b. Ureteroplasty: surgical repair of ureter for stricture or structural abnormality; reimplantation if vesicoureteral reflux; clients usually return from surgery with catheter and ureteral stent in place for 3 5 days 9. Nursing Care: Health promotion to prevent UTI a. Fluid intake 2 2.5 L daily, more if hot weather or strenuous activity is involved b. Empty bladder every 3 4 hours c. Females 1. Cleanse perineal area from front to back 2. Void before and after sexual intercourse 3. Maintain integrity of perineal tissues a. Avoid use of commercial feminine hygiene products or douches b. Wear cotton underwear d. Maintain acidity of urine (use of cranberry juice, take Vitamin C, avoid excess milk and milk products, sodium bicarbonate) 10. Nursing Diagnoses a. Pain: Additional interventions include warmth, analgesics, urinary analgesics, antispasmodic medications b. Impaired Urinary Elimination c. Ineffective Health Maintenance: Clients must complete full course of antibiotic therapy 11. Home Care: Teaching: prevention of infection and use alternatives to indwelling catheter whenever possible II. Client with Urinary Calculi A. Background 1. Urinary calculi are stones in urinary tract a. Nephrolithiasis: stones form in kidneys b. Urolithiasis: stones form in urinary tract outside kidneys 2. Highest incidence in southern and Midwestern states 3. Males more often affected than females (4:1) 4. Most common in young and middle adults B. Risk factors 1. Majority of stones are idiopathic (no demonstrable cause) 2. Prior personal or family history of urinary calculi 3. Dehydration: increased urine concentration 4. Immobility 5. Excess dietary intake of calcium, oxalate, protein 6. Gout, hyperparathyroidism, urinary stasis, repeated UTI infection C. Pathophysiology 1. Factors leading to lithiasis include supersaturation (high concentration of insoluble salt in urine), pH of urine 2. Types of calculi a. Calcium stones (calcium oxalate, calcium phosphate) 1. Associated with high concentrations of calcium in blood or urine 2. Genetic link b. Uric acid stones 1. Associated with high concentration of uric acid in urine 2. Genetic link 3. More common in males 4. Associated with gout c. Sturvite stones 1. Associated with UTI caused by bacteria Proteus 2. Stones are very large 3. Staghorn stones in renal pelvis and calyces d. Cystine stones: Associated with genetic defect D. Manifestations: depends upon size and location of stones 1. Calculi affecting kidney calices, pelvis a. Few symptoms unless obstructed flow b. Dull, aching flank pain 2. Calculi affecting bladder a. Few symptoms b. Dull suprapubic pain with exercise or post voiding c. Possibly gross hematuria 3. Calculi affecting ureter, causing ureteral spasm a. Renal colic: acute, severe flank pain of affected side, radiates to suprapubic region, groin, and external genitals b. Nausea, vomiting, pallor, cool, clammy skin 4. Manifestations of UTI may occur with urinary calculi E. Complications 1. Obstruction: manifestations depend upon speed of obstruction development; can ultimately lead to renal failure 2. Hydronephrosis: distention of renal pelvis and calyces; unrelieved pressure can damage kidney (collecting tubules, proximal tubules, glomeruli) leading to gradual loss of renal function

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a. Acute: colicky pain on affected side b. Chronic: few manifestations: dull ache in back or flank c. Other manifestations: hematuria, signs of UTI, GI symptoms Collaborative Care 1. Relief of acute symptoms 2. Remove or destroy stone 3. Prevent future stone formation Diagnostic Tests 1. Urinalysis: hematuria, possible WBCs and crystal fragments, urine pH helpful to diagnose stone type 2. Chemical analysis of stone: All urine must be strained and saved; stones or sediment sent for analysis 3. 24-urine collection for calcium, uric acid, oxalate to identifiy possible cause of lithiasis 4. Serum calcium, phosphorus, uric acid: identify factors in calculi formation 5. KUB xray (kidney, ureters, bladder): flat plate to identify presence and location of opacities 6. Renal ultrasonography: sound waves to detect stones and detect hydronephrosis 7. CT scan of kidney: identify calculi, obstruction, disorders 8. IVP 9. Cystoscopy: visualize and possibly remove calculi from urinary bladder and distal ureters Medications 1. Treatment of acute renal colic: analgesia and hydration 2. Narcotic such as intravenous morphine sulfate, NSAID, large amounts of fluid by oral or intravenous routes 3. Medications to inhibit further lithiasis according to analysis of stone: a. Thiazide diuretics: promotes reduction of urinary calcium excretion b. Potassium citrate: used to alkalinize urine for stones formed in acidic urine (uric acid, cystine, and some calcium stones) Dietary Management: Prescribed to change character of urine and prevent further lithiasis 1. Increased fluid intake to 2 2.5 liters daily, spaced throughout day 2. Limited intake of calcium and Vitamin D sources if calcium stones 3. Phosphorus and/or oxalate may be limited with calcium stones 4. Low purine (rich meats) diet for clients with uric acid stones 5. Control of pH to maintain pH that inhibits lithiasis a. Promote alkaline urine for clients with uric acid or cystine stones b. Promote acid urine for clients with calcium stones or urinary tract infections Lithotripsy: Use of sound or shock waves to crush stones 1. Extracorporeal shock-wave lithotripsy: acoustic shock waves aimed under fluoroscopic guidance to pulverize stone into fragments small enough to be eliminated in urine; sedation or TENS used to maintain comfort during procedure 2. Percutaneous ultrasonic lithotripsy: nephroscope inserted into kidney pelvis through small flank incision; stone fragmented using small ultrasonic transducer and fragments removed through nephroscope 3. Laser lithotripsy: stone is disintegrated by use of laser beams; nephroscope or ureteroscope used to guide laser probe 4. Stent may be inserted into affected ureter after procedure to maintain patency after lithotripsy procedures Surgery 1. May be indicated as treatment depending on stone location, severe obstruction, infection, serious bleeding 2. Types: a. Ureterolithotomy: incision into affected ureter to remove calculus b. Pyelolithotomy: incision into and removal of stone from kidney pelvis c. Nephrolithotomy: surgery to remove staghorn calculus in calices and renal parenchyma d. Cystoscopy: crushing and removal of bladder stones through cystocope; stone fragments irrigated out of bladder with acid solution Nursing Care 1. Focus on comfort during renal colic, diagnostic procedures, ensure adequate urine output, prevent future stone formation 2. Health promotion: adequate fluid intake for all clients, adequate weight-bearing activity to prevent bone resorption, hypercalcuria, prevention of UTI Nursing Diagnoses 1. Acute Pain a. Adequate pain management b. Intensity of pain can cause vaso-vagal response; client may experience hypotension, syncope; client safety must be maintained 2. Impaired Urinary Elimination a. Teaching client and strain all urine; send recovered stones for analysis b. Complete obstruction causes hydronephrosis on involved side; other kidney continues forming urine; monitor BUN, Creatinine c. Maintain patency and integrity of all catheters; all catheters need to be labeled, secured, and sterility maintained 3. Deficient Knowledge: Client participation in treatment and prevention Home Care 1. Education regarding management current treatment and prevention 2. Clients may be discharged with catheters, tubes, dressings; home care referral

III. Client with Urinary Retention A. Definition 1. Incomplete emptying of bladder leading to overdistention of bladder 2. Poor bladder contractility 3. Inability to urinate 4. May develop hydronephrosis B. Pathophysiology 1. Mechanical obstruction of bladder outlet or functional problem leads to urinary retention including a. Benign prostatic hypertrophy (BPH) b. Acute inflammation associated with infection or trauma of bladder c. Status post abdominal or pelvic surgery disrupting detrusor muscle function d. Anticholinergic medications e. Failure to void regularly, resulting in bladder overfill and loss of detrusor muscle tone 2. Client may experience overflow voiding or incontinence 25 50 ml at frequent intervals C. Collaborative Care: Treatment focuses on removing or repairing obstruction, e.g. prostrate gland resection D. Treatment may include 1. Catheterization indwelling or intermittent 2. Cholinergic medications such as bethanechol chloride (Urecholine) promoting detrusor muscle contraction and bladder emptying 3. Elimination of medications with anti-cholinergic effects E. Nursing Care 1. Focus on monitoring urine output of at risk clients including those receiving medications that interfere with detrusor muscle function 2. With acute urinary retention, catheterization may be necessary; if bladder is overdistended, drain only 500 ml at 5 10 minute intervals to prevent vaso-vagal response and hematuria F. Home Care: Specific teaching depends on prescribed treatment which may include 1. Intermittent self-catheterization 2. Care with over the counter medications that may have anticholinergic effects 3. Double voiding; scheduled voiding 4. Indwelling catheter IV. Client with Urinary Incontinence A. Background 1. Urinary incontinence is involuntary urination; leads to a. Physical problems including skin breakdown and infection b. Psychosocial aspects: embarrassment, isolation, depression 2. Up to 30% older women in community have incontinence; 50% of long term care and home bound populations B. Pathophysiology 1. Pressure within the urinary bladder exceeds urethral resistance 2. Conditions leading to incontinence include a. Relaxation of pelvic musculature b. Disruption of cerebral and nervous system control c. Disturbances in bladder and its musculature 3. Acquired, irreversible causes include chronic neurological conditions 4. Acute, reversible causes include confusion, effects of medications, prostatic enlargement, vaginal and urethral atrophy, UTI, fecal impaction 5. Categories include a. Stress incontinence b. Urge incontinence (overactive bladder) c. Overflow incontinence d. Functional incontinence e. Mixed incontinence (stress and urge) 6. Incontinency associated with increased risk for falls, pressure ulcers, UTI, depression, caregiver stress, and cause for institutionalizing client C. Collaborative Care 1. Focus is identification and correction of cause if possible; otherwise management of urinary output 2. Evaluation includes history including duration, frequency, volume and circumstances associated with incontinence (e.g. prostatic enlargement, cystocele, rectocele); voiding diary D. Diagnostic Tests 1. Urinalysis and urine culture: assess for UTI 2. Postvoiding residual: < 50 ml is expected; >100 ml indicates need for further testing 3. Cystometrography: evaluation of neuromuscular function of bladder; urge to void occurs at 150 450 ml; bladder feels full at 300 500 ml. 4. Uroflowmetry: noninvasive test to evaluate voiding pattern 5. IVP: evaluates structure and function of urinary tract 6. Cystoscopy or ultrasound: identify structural disorders E. Medications 1. Mild stress incontinence may be improved by using medications that contract smooth muscles of bladder neck such as phenylpropanolamine which is often used in over the counter decongestants and diet aids 2. Incontinence with postmenopausal atrophic vaginitis responds to topical estrogen therapy 3. Urge incontinence treated with medications that increase bladder capacity: oxybutynin (Ditropan), tolterodine (Detrol) 4. Clients may have other medical conditions adversely affected by medications used to treat incontinence

Surgery: Treatments for stress incontinence 1. Suspension of bladder neck by laparoscopic, vaginal, or abdominal approach treats stress incontinence associated with cystocele 2. Prostatectomy may be used to treat enlarged prostate gland and urethral obstruction G. Complementary Therapies: Biofeedback and relaxation techniques H. Nursing Care 1. Health promotion includes education that incontinence is not normal with aging 2. Educate females about pelvic floor exercises 3. Educate males about treatment for prostatic enlargement 4. Availability of therapies and health practitioners I. Nursing Diagnoses 1. Urinary Incontinence: stress and/or urge a. Clients with difficulty emptying bladder should not stop flow while voiding b. Limit fluids that are irritating to bladder: caffeine, alcohol, citrus juices, artificial sweeteners 2. Self-care Deficit: Toileting a. Assist client in independence b. Planned toileting schedule 3. Social Isolation J. Home Care 1. Assisting clients to deal effectively with incontinence lessens risk for institutionalization; address causes, availability of treatment, management interventions 2. Assess toileting environment for safety and assist to obtain mobility aids such as safety bar, raised toilet seat 3. Clients who have had bladder neck suspension surgery often are discharged with catheter in place; client and family teaching, home health referral

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Nursing Care of Clients with Kidney Disorders

I. Age-Related Changes in Kidney Function A. Decline in glomerular filtration rate (GFR) to half or less related to 1. Arteriosclerosis 2. Decreased renal vascularity 3. Decreased cardiac output B. Reduced clearance of drugs excreted through kidneys: prolonged half-life of such medications as 1. Cardiac drugs: digoxin, procainamide 2. Antibiotics: aminoglycosides, tetracyclines, cephalosporins 3. Histamine H2 antagonists: cimetidine 4. Antidiabetic agents: chlorpropamide C. Increased risk for fluid and electrolyte imbalance 1. Decreased ability to concentrate urine and compensate for altered salt intake 2. Decreased effectiveness of antidiuretic hormone (ADH) and reduced thirst response 3. Decreased potassium excretion due to lower aldosterone levels

II. Client with a Congenital Kidney Malformation A. Affect form and function of kidney 1. Agenesis: absence of kidney; renal function normal as long as other kidney is functioning 2. Hypoplasia: underdevelopment of kidney; renal function normal as long as other kidney is functioning 3. Horseshoe kidney: embryonic kidney fails to ascend normally and result in single horseshoe-shaped organ; increased risk for hydronephrosis and recurrent UTI, renal calculi B. Education is important to maintain and prevent renal complications from developing III. Client with Polycystic Kidney Disease A. Definition 1. Hereditary disease characterized by cyst formation and massive kidney enlargement 2. Adult form of disorder is autosomal dominant polycystic kidney disease and accounts for 10% of persons in End Stage Renal Disease (ESRD) B. Pathophysiology 1. Renal cysts are fluid-filled sacs affecting nephrons; cysts fill, enlarge, multiply thus compressing and obstructing kidney tissue; renal parenchyma atrophies, becomes fibrotic 2. Cysts occur elsewhere in body including liver, spleen C. Manifestations 1. Disease is slowly progressive; symptoms develop in age 30 40s 2. Common manifestations include a. Flank pain b. Microscopic or gross hematuria c. Proteinuria d. Polyuria and nocturia (impaired ability to concentrate urine) e. UTI and renal calculi are common f. Hypertension from disrupted renal vessels g. Kidneys become palpable, enlarged, knobby h. Symptoms of renal insufficiency and chronic renal failure by age of 50 60 D. Collaborative Care: Determine extent of polycystic kidney disease

E. Diagnostic tests 1. Renal ultrasonography: primary choice for diagnostic; assesses kidney size, identifies and locates renal masses: cysts, tumors, calculi 2. Intravenous pyelography (IVP): evaluate structure and excretory function of kidneys, ureters, bladder 3. CT scan of kidneys: detects and differentiates renal masses F. Management 1. Mainly supportive: prevent further renal damage from UTI, nephrotoxic substances, obstruction, hypertension 2. Fluid intake of 2000 2500 mL to prevent UTI, calculi 3. Control of hypertension with ACE inhibitors and other antihypertensive agents 4. Eventually require dialysis or transplantation (typically good candidates) G. Nursing Care and Nursing Diagnoses 1. Risk for Ineffective Coping: address genetic counseling and screening for family members 2. Excess Fluid Volume 3. Anticipatory Grieving 4. Knowledge Deficit: of measures to preserve kidney function IV. Client with a Glomerular Disorder A. Definition 1. Leading cause of chronic renal failure in U. S. 2. Primary disorders involve mainly kidney a. Immunologic b. Idiopathic 3. Secondary disorders relate to inherited or multisystem disease a. Diabetes mellitus b. Systemic lupus erythematosus (SLE) c. Goodpastures syndrome B. Pathophysiology 1. Glomerular disease affects structure and function of glomerulus affecting filtration and increasing permeability in glomerulus 2. Results in manifestations a. Hematuria b. Proteinuria (most important indicator; increases progressively with glomerular damage) c. Edema (results from hypoalbuminemia) 3. GFR falls resulting in azotemia (increased blood level of nitrogenous waste products) and hypertension 4. Involvement may be diffuse (all glomeruli) or focal (some glomeruli) 5. Oliguria (urine output < 400 ml in 24 ml) C. Primary glomerular disorders 1. Acute glomerulonephritis a. Inflammation of glomerular capillary membrane b. Most common form is poststreptococcal glomerulonephritis c. Circulating antigen-antibody immune complexes formed in primary infection are trapped in glomerular membrane; complement system activiated; glomeruli inflamed and increasingly permeable d. Manifestations 1. Abrupt onset of hematuria, proteinuria, salt and water retention, azotemia 10 14 days post initial infection 2. Urine is cocoa or coffee-colored 3. Edema noted in face, particularly periorbital, dependent edema in hands and upper extremities 4. Fatigue, anorexia, nausea, vomiting 5. Older adults have less apparent symptoms: nausea, malaise, arthralgias, proteinuria, pulmonary infiltrates e. Adults: 60% recover fully; remainder have persistent symptoms and permanent kidney damage 2. Rapidly progressive glomerulonephritis (RPGN) a. Severe glomerular damage without specific identifiable cause b. Primary or secondary to SLE or Goodpastures syndrome c. Diffuse glomerular damage with rapid progressive disease with irreversible renal failure over weeks to months d. May have flulike illness preceding onset resulting in oliguria, abdominal or flank pain, moderate hypertension, hematuria, proteinuria 3. Chronic glomerulonephritis a. Typically end stage of other glomerular disorders (RPGN, lupus nephritis, diabetic nephropathy) b. Symptoms develop insidiously, may be unrecognized until signs of renal failure develop c. Course of disease varies with time between diagnosis and development of end-stage renal failure 4. Nephrotic syndrome a. Group of clinical findings, not specific disorder b. Characterized by 1. Massive proteinuria 2. Hypoalbuminemia 3. Hyperlipidemia 4. Edema (often facial and periorbital) c. Several disorders affect glomerular capillary membrane d. Clients have increased risk for atherosclerosis e. Complication is thromboemboli leading to renal vein and deep vein thrombosis, pulmonary embolism f. Adults: < 50% recover; remainder develop persistent proteinuria and progress to ESRD

D. Common secondary forms of glomerular disease 1. Diabetic nephropathy a. Leading cause of ESRD in U. S. b. 30% of clients with diabetes type 1; 20% of clients with diabetes type 2 c. Initial evidence is microproteinuria typically seen 10 15 years after onset of diabetes; nephropathy develops within 15 20 years after initial diagnosis d. Characteristic lesion is glomerulosclerosis and thickening of glomerular basement membrane e. Arteriosclerosis and hypertension contribute to disease 2. Lupus nephritis a. 40 85% of clients develop manifestations of nephritis b. Immune complexes trigger glomerular injury c. Manifestations range from microscopic hematuria to massive proteinuria; progression varies form slow and chronic to fulminant d. Improved management and dialysis and transplantation improved prognosis E. Collaborative Care 1. Identification of underlying disease process 2. Preservation of renal function F. Diagnostic Tests 1. Throat or skin cultures: detect group A beta-hemolytic streptococci; used with identification of poststreptococcal glomerulonephritis 2. Antistreptolysin O (ASO) titer: detect streptococcal exoenzymes; used with identification of poststreptococcal glomerulonephritis 3. Erythrocyte sedimentation rate (ESR): indicator of inflammatory response as with poststreptococcal glomerulonephritis or lupus nephritis 4. KUB (kidney, ureters, bladder) abdominal xray: evaluate kidney size; enlarged with acute glomerulonephritis; small with chronic glomerulonephritis 5. Kidney scan: nuclear medicine procedure reveals delayed uptake with glomerular disease 6. Biopsy: microscopic examination of kidney tissue most reliable diagnostic procedure for glomerular disorders; determines type, prognosis, and appropriate treatment of glomerulonephritis 7. Serum BUN, Creatinine: evaluate kidney function; creatinine is good indicator of kidney function since entirely excreted by kidneys 8. Urine creatinine: levels decrease with impaired renal function 9. Creatinine clearance: very specific indicator of renal function and GFR 10. Serum electrolytes: evaluate values affected by impaired kidney function, especially serum potassium 11. Urinalysis: shows red blood cells, abnormal protein 12. 24-hour urine for protein: determine amount of protein in urine G. Medications 1. Not curative but treatment for underlying disorders, decrease inflammation, symptom management 2. Antibiotics: treatment for poststreptococcal glomerulonephritis if any remaining bacteria (avoid nephrotoxic antibiotics) 3. Immunosuppressive therapy: aggressively treat acute inflammatory processes (RPGN), Goodpastures syndrome, SLE a. Prednisone, glucocorticoid in large doses b. Cyclophosphamide (Cytoxan) or azathioprine (Imuran) c. ACE inhibitors to reduce protein loss associated with nephrotic syndrome, diabetic nephropathy d. Antihypertensive medications H. Treatment 1. Bedrest: treatment of acute phase of poststreptococcal glomerulonephritis 2. Sodium restriction to 1 2 gm/day with nephrotic syndrome 3. Protein intake may be restricted and should be of high biologic value (complete proteins: have all essential amino acids) 4. Plasmapheresis: procedure to remove damaging antibodies 5. Dialysis procedures I. Nursing Care: Health Promotion 1. Effective treatment of streptococcal infections with completion of full course of antibiotics 2. Effective management of chronic conditions such as diabetes mellitus and SLE and hypertension 3. Avoiding potentially nephrotoxic medications J. Nursing Diagnoses 1. Excess Fluid Volume: monitor effects on cardiac workload, blood pressure, respiratory status 2. Fatigue: manifestation of anemia, hypoproteinemia, anorexia, nausea 3. Ineffective Protection: increased risk for infection 4. Ineffective Role Performance K. Home Care 1. Teach clients that glomerular disorders are self-limiting or progressive 2. Course is lengthy 3. Self-management is essential V. Clients with Renal Failure A. Definition 1. Condition in which kidneys are unable to remove accumulated metabolites from blood; leads to altered fluid, electrolyte and acid-base balance 2. May be due to kidney (primary disorder) or resulting from another disease in another organ or systemic (secondary disorder) 3. Classified as acute (abrupt onset and may be reversible) or chronic (develops slowly and insidiously with few symptoms until kidneys are severely damaged and unable to meet bodys excretory needs)

4. Common and costly disease with people with End Stage Renal Disease requiring dialysis or transplant to live 5. 5 year survival rate for clients on dialysis is 31.3% B. Acute Renal Failure (ARF) 1. Definition a. Rapid decline in renal function with azotemia fluid and electrolyte imbalances b. High mortality rate but is related to clients being seriously ill and aged 2. Risk Factors a. Major surgery or trauma b. Infection c. Hemorrhage d. Severe heart failure, liver disease e. Lower urinary tract obstruction f. Use of nephrotoxic contrast media and medications 3. Pathophysiology involved with cause categories a. Prerenal 1. 55 60% cases of ARF 2. Cause: Conditions that affect renal blood flow and perfusion a. Decrease vascular volume b. Decrease cardiac output c. Decrease vascular resistance b. Intrarenal 1. 35-40% cases of ARF 2. Cause: Acute damage to renal parenchyma and nephron a. Acute glomerulonephritis b. Vascular disorders including vasculitis, malignant hypertension, arterial or venous occlusion c. Acute Tubular Necrosis (ATN): Destruction of tubular epithelial cell with abrupt decline in renal function from 1. Prolonged ischemia (>2 hours) as with surgery, severe hypovolemia, sepsis, trauma, burns 2. Nephrotoxins a. Aminoglycoside antibiotics b. Radiologic contrast media c. Other potential drugs: NSAIDs, heavy metals, ethylene glycol (antifreeze) 3. Nephrotoxins have increased risk with clients with preexisting renal insufficiency or state of dehydration 4. Rhabdomyolysis: excess myoglobin from skeletal muscle injury clogs renal tubules (muscle trauma, drug overdose, infection) 5. Hemolysis: red blood cell destruction c. Postrenal 1. <5% cases of ARF 2. Cause: Obstructive; prevents urine excretion a. Benign prostatic hypertrophy b. Renal or urinary tract calculi or tumors 4. Course and Manifestations of ARF in 3 phases a. Initiation Phase 1. Lasts hours to day 2. Begins with initiating event ends when maintenance phase begins 3. Good prognosis if treated at this phase 4. Few manifestations; identified when maintenance phase begins b. Maintenance Phase 1. Characterized by significant fall in GFR and tubular necrosis 2. Oliguric or non-oliguric but kidneys not eliminating wastes, water, electrolytes, acids: azotemia, fluid retention, electrolyte imbalances (hyperkalemia, hypocalcemia, hyperphosphatemia), acidosis (impaired hydrogen ion elimination) 3. Anemia after several days due to suppressed erythropoetin secretion; impaired immune function 4. Salt and water retention leading to hypertension and risk for heart failure and pulmonary edema 5. Hyperkalemia: cardiac dysrhythmias and EKG changes, muscle weakness, nausea, diarrhea 6. Confusion, disorientation, agitation or lethargy, hyperreflexia, possible seizures, coma 7. Vomiting, decreased or absent bowel sounds c. Recovery Phase 1. Progressive tubule cell repair and regeneration; return of GFR to pre-ARF levels 2. Diuresis occurs as kidney recover but BUN, Creatinine, potassium and phosphate remain high 3. Renal function improves rapidly first 5 25 days but improvement may continue for up to a year 5. Collaborative Care a. Prevention of ARF is goal for all clients, especially those at high-risk 1. Preserve kidney perfusion by adequate vascular volume, cardiac output and blood pressure 2. Limiting use of nephrotoxic medications or using minimal effective dose, maintaining hydration, monitoring renal function tests

b. Treatment goals 1. Identify and correct underlying cause 2. Prevent additional renal damage 3. Restore urine output and kidney function 4. Compensate for impaired renal function: maintain fluid and electrolyte balance 6. Diagnostic tests to identify ARF a. Urinalysis 1. Fixed specific gravity 1.010 (low) 2. Proteinuria, if glomerular damage 3. Presence of red blood cells (glomerular dysfunction), white blood cells (inflammation), renal tubule epithelial cells (ATN) 4. Cell casts (protein and cellular debris molded in shape of tubular lumen); brown color may indicate hemoglobinuria or myoglobinuria b. Serum BUN and creatinine 1. Creatinine rises rapidly (24 48 hours) and peaks in 5 10 days; rise is slower if output maintained 2. Halt in rise of BUN and Creatinine signals onset of recovery c. Serum Electrolytes 1. Monitored to determine whether to initiate dialysis 2. Moderate rise in potassium 3. Hyponatremia related to water excess d. CBC showed moderate anemia and low hematocrit (Iron and folate may be low and add to anemia) e. Renal ultrasound: used to identify any obstruction, identify acute from chronic renal failure f. CT scan: identify obstruction and kidney size g. IVP, retrograde pyelography, or antegrade pyelography 1. Assess renal structure and function 2. Retrograde and antegrade testing less toxicity from contrast media h. Renal biopsy: determine cause, differentiate acute from chronic 7. Medications a. Intravenous fluids and blood volume expanders to restore renal perfusion b. Low dose Dopamine (Intropin) intravenous infusion to increase renal blood flow and improve cardiac output c. Diuretic: Furosemide (Lasix) or osmotic diuretic such as mannitol along with intravenous fluids; washes out nephrons; prevents oliguria reducing azotemia and electrolyte imbalance d. Antihypertensive medications including ACE inhibitors to limit renal injury e. Medications to prevent possible complications 1. Prevention of gastrointestinal bleeding (at risk due to stress, impaired platelet function) a. Antacids b. H2 receptor antagonists c. Proton-pump inhibitors 2. Hyperkalemia: serum K > 6.5 mEq/L puts client at risk for cardiac arrest a. Calcium chlorides b. Bicarbonate c. Insulin and glucose d. Sodium polystyrene sulfonate (Kayexalete) 1. Removes potassium from body primarily in large intestine 2. If given orally, is combined with sorbitol 3. May be given as retention enema with tap water enema to follow after 30 60 minutes 3. Hyperphosphatemia a. Aluminum hydroxide (AlternaGEL, Amphojel, Nephrox) b. Binds with phosphates in GI tract and is eliminated from bowel 8. Fluid Management a. Once vascular volume and renal perfusion restored, fluids are restricted b. Often intake is calculated by adding output from previous 24 hours and 500 ml for insensible losses c. Fluid balance monitored by daily weights and serum Na level 9. Dietary Management a. Renal insufficiency and underlying disease creates increased rate of catabolism (breakdown of body proteins) and decreased rate of anabolism (tissue repair) b. Client needs adequate nutrition and calories to prevent catabolism but protein intake needs to be limited to minimize azotemia c. Protein limited to 0.6g/kg body weight per day; protein should be of high biologic value (contains essential amino acids) d. Carbohydrate intake is increased for adequate calories and protein-sparing effect 10. Dialysis a. Dialysis is the diffusion of solute molecules across semipermeable membrane from area of higher solute concentration to lower concentration b. Dialysis used to remove excess fluid, waste products from client with renal failure; can rapidly remove nephrotoxins from blood 11. Hemodialysis: Dialysis process a. In this type of dialysis, blood is taken from client via vascular access and pumped into a dialyzer; blood is separated from the dialysate (dialysis solution) by semipermeable membrane b. Processes of diffusion and ultrafiltration remove waste products, electrolytes, excess water

Glucose, electrolytes, water can pass through, but larger molecules (protein, red blood cells) are blocked d. Substances can be added to dialysate to diffuse into the blood of the client e. Client with ARF may undergo hemodialysis daily initially, then 3 4 times/week according to client condition; 3 4 hours at a time 12. Complications associated with hemodialysis a. Hypotension, most common, related to changes in osmolality, rapid removal from vascular department, vasodilation b. Bleeding related to platelet function and use of heparin during dialysis c. Infection, local or systemic; Staphylococcus aureus septicemia associated with infected vascular access site; higher rates of hepatitis B and C, cytomegalovirus, HIV in hemodialysis clients 13. Continuous Renal Replacement Therapy (CRRT) a. Technique used, which allows more gradual fluid and solute removal than hemodialysis; used for clients with ARF unable to tolerate hemodialysis b. Done over period of 12 hours or more 14. Vascular Access for Hemodialysis a. Acute or temporary access is gained inserting double lumen catheter into subclavian, jugular, or femerol vein b. Blood is drawn from proximal portion of catheter and returned to circulation through distal end of catheter c. Arteriovenous (AV) fistula created for longer term access for dialysis 1. Surgical anastomosis of artery and vein in non-dominant arm, usually radial artery and cephalic vein 2. Usually cannot use fistula for hemodialysis access for a month while it matures 3. Nurse or client can assess functional fistula for complications a. Thrombosis (clotted off): check for palpable thrill, audible bruit b. Infection: check for redness, drainage 4. Venipunctures and blood pressures should not be done in arm with the AV fistula 5. AV fistulas are commonly used for vascular access for dialysis clients with chronic renal failure 15. Peritoneal dialysis process involves: a. Peritoneal membrane of client is used as dialyzing surface b. Warmed sterile dialysate instilled into peritoneal cavity through a catheter that has been inserted into peritoneal cavity c. Metabolic waster products and excessive electrolytes diffuse into dialysate while it remains in abdomen d. Water diffusion is controlled by glucose in the dialysate which acts as an osmotic agent e. Fluid is drained off by gravity into sterile bag at set intervals, thus removing waste products and excess fluid 16. Disadvantages of peritoneal dialysis a. Dialysis is more gradual and may be slow for ARF b. Risk of peritonitis c. Contraindicated for clients with abdominal surgery, peritonitis, significant lung disease 17. Health Promotion: Prevention of ARF a. Maintenance of fluid volume and cardiac output b. Reduce risk of exposure to nephrotoxins c. Report output < 30 ml per hour in clients at risk d. Report dehydration, monitor renal function tests in clients receiving nephrotoxic medications e. Observe clients for signs of transfusion reactions 18. Nursing Diagnoses for clients in ARF a. Excess Fluid Volume b. Imbalanced Nutrition: Less than body requirements c. Deficient Knowledge 19. Home care: Client who is recovering from ARF will need teaching for prescribed diet and fluid intake, avoidance of nephrotoxins, prevention of infection, continue under medical supervision C. Client with Chronic Renal Failure (CRF) 1. Definition a. Progressive renal tissue destruction and loss of function b. May progress over many years without being recognized until kidneys are unable to excrete metabolic wastes and regulate fluid and electrolytes: End-stage Renal Disease (ESRD) c. Incidence is increasing especially in older adults; higher in African Americans, Native Americans d. Conditions causing chronic renal failure diffuse bilateral disease of kidneys with progressive destruction and scarring; diabetes is leading cause of ESRD; then hypertension 2. Pathophysiology and Manifestations of Stages a. Decreased Renal Reserve: Early Stage 1. Unaffected nephrons compensate for lost nephrons 2. GFR is about 50% of normal 3. Client is asymptomatic 4. BUN and serum creatinine are normal b. Renal Insufficiency 1. GRF falls to 20 50% of normal 2. Azotemia and some manifestations 3. Insult to kidneys could precipitate onset renal failure (infection, dehydration, exposure to nephrotoxins, urinary tract obstructions)

c.

3.

4.

5.

Renal failure 1. GRF < 20% of normal 2. BUN and serum creatinine rise sharply 3. Oliguria, manifestations of uremia d. End-stage renal disease (ESRD) 1. GRF < 5 % of normal 2. Renal replacement therapy necessary to sustain life ESRD: Uremia (urine in blood) a. Early manifestations 1. Nausea, apathy, weakness, fatigue 2. Progresses to frequent vomiting, increasing weakness, lethargy, confusion b. Fluid and electrolyte effects 1. Urine less concentrated with proteinuria and hematuria 2. Sodium and water retention 3. Hyperkalemia (Muscle weakness, paresthesia, EKG changes) 4. Hyperphosphatemia, hypocalcemia, hypermagesemia 5. Metabolic acidosis c. Cardiovascular effects 1. Systemic hypertension 2. Edema and heart failure; pulmonary edema 3. Pericarditis: metabolic toxins irritate pericardial sac; less often now with dialysis 4. Cardiac tamponade: fluid in pericardial sac d. Hematologic effects 1. Anemia contributing to fatigue, weakness, depression, impaired cognition, impaired cardiac function 2. Impaired platelet function e. Immune system effects 1. WBC declines 2. Humoral and cell-mediated immunity impaired 3. Fever suppressed f. Gastrointestinal effects 1. Anorexia, nausea, vomiting, hiccups 2. GI ulcerations, increased risk for GI bleeding 3. Uremic fetor: urinelike breath odor g. Neurologic effects 1. Changes in mentation, poor concentration 2. Fatigue, insomnia 3. Psychotic symptoms, seizures, coma 4. Peripheral neuropathy: restless leg syndrome, sensations of crawling, prickling 5. Muscle weakness, decreased deep tendon reflexes, gait disturbances h. Musculoskeletal effects 1. Renal osteodystrophy (renal rickets) characterized by osteomalacia (bone softening) and osteoporosis 2. Bone tenderness and pain i. Endocrine and metabolic effects 1. Elevated uric acid levels; risk for gout 2. Resistance to insulin, glucose intolerance 3. High triglyceride and < HDL levels resulting in accelerated atherosclerotic process 4. Menstrual irregularities; reduced testosterone levels j. Dermatologic effects 1. Yellowish hue to skin 2. Dry skin with poor turgor 3. Pruritis due to metabolic wastes deposited in skin 4. Uremic frost crystallized deposits of urea on skin Collaborative Care a. Eliminate factors that further decrease renal function b. Maintenance of nutritional status with minimal toxic waste products c. Identify and treat complications of CRF d. Preparation for dialysis or renal transplantation Diagnostic Tests: Identify CRF and monitor renal function by following levels of metabolic wastes and electrolytes a. Urinalysis: fixed specific gravity at 1.010; excess protein, blood cells, cellular casts b. Urine culture: identify infection c. BUN and serum creatinine: evaluate kidney function 1. BUN levels a. Mild azotemia: 20 50 mg/dL b. Severe renal impairment: > 100 mg/dL c. Uremic symptoms: > 200mg/dL 2. Creatinine levels >4 mg/dL indicate serious renal impairment d. Creatinine Clearance: evaluates GFR and renal function 1. Decreased renal reserve: 32.5 130 mL/min 2. Renal insufficiency: 10 30 mL/min 3. ESRD: 5 10 mL/min e. Serum electrolytes: monitored throughout course of CRF

c.

CBC: moderately severe anemia with hematocrit 20 30%; low hemoglobin; reduced RBCs and platelets g. Renal ultrasonography: CRF: decreased kidney size h. Kidney biopsy: diagnose underlying disease process; differentiate acute from chronic 6. Medications a. General effects of CRF on medication effects 1. Increased half-life and plasma levels of meds excreted by kidneys 2. Decreased drug absorption if phosphate-binding agents administered concurrently 3. Low plasma protein levels can lead to toxicity when protein-bound drugs are given 4. Avoid nephrotoxic meds or give with extreme caution b. Diuretics (furosemide, other loop diuretics) 1. Reduce edema 2. Reduce blood pressure 3. Lower potassium c. Antihypertensive medications: ACE inhibitors preferred d. Sodium bicarbonate or calcium carbonate correct mild acidosis e. Oral phosphorus binding agents (calcium carbonate, calcium acetate) to lower phosphate levels and normalize calcium levels f. Aluminum hydroxide for acute treatment of hyperphosphatemia g. Vitamin D supplements to improve calcium absorption h. To treat dangerously high potassium levels 1. Intravenous bicarbonate, insulin, glucose 2. Sodium polystyrene sulfonate (Kayexalate) i. Folic acid, iron supplements to combat anemia j. Multiple vitamin supplement 7. Dietary and Fluid Management a. Early in course of CRF: diet modifications to slow kidney failure, uremic symptoms, and complications b. Restrict proteins (40 gm/day) of high biologic value c. Increase carbohydrate intake (35kcal/kg/day) d. Limit fluid to 1 2 L per day; limit sodium to 2 g/day e. Restrict potassium (60 -70 mEq/day); no salt substitutes f. Restrict phosphorus foods (meat, eggs, dairy products) 8. Renal Replacement Therapies: considered when medications and dietary modifications are no longer effective a. Hemodialysis: establish vascular access (create AV fistula) months ahead b. Peritoneal dialysis: can be initiated when indicated; training client and/or family involved c. Transplantation: tissue typing and identification of living related potential donors including health assessment of donor 9. Dialysis a. Considerations 1. Dialysis manages ESRD, but does not cure it 2. Hemodialysis or peritoneal dialysis is constant factor of life 3. Depending on individual client situation and total health, client may prefer death to dialysis b. Hemodialysis for ESRD 1. Treatments are 3 times per week for 9 12 hours 2. Specific dialysis orders according to body size, residual renal function (based on that days current lab test results), dietary intake, concurrent illnesses 3. Complications during treatment are hypotension and muscle cramps; dialysis disequilibrium syndrome 4. Long term complications are infection and vascular access problems 5. Cardiovascular disease is leading cause of death for hemodialysis clients; higher death rate than clients on peritoneal dialysis or transplanted c. Peritoneal Dialysis for ESRD 1. Continuous ambulatory peritoneal dialysis (CAPD) most common 2. 2 liters of dialysate instilled into peritoneal cavity and catheter sealed; empty and replace every 4 6 hours 3. Continuous cyclic peritoneal dialysis (CCPD) uses delivery device during nighttime hours and continuous dwell during day 4. Advantages over hemodialysis a. Eliminates vascular access and heparinization b. Avoids rapid fluctuation in extracellular fluid c. Diet intake is more liberal with fluids and nutrients d. Regular insulin can be added to dialysate to manage hyperglycemia for diabetics e. Client more able to self-manage 5. Disadvantages of peritoneal dialysis a. Less effective metabolite elimination b. Risk for infection (peritonitis: dialysate returns cloudy; should be straw colored) c. Serum triglyceride levels increase d. Altered body image with peritoneal catheter 10. Kidney Transplant a. Background 1. Treatment of choice for ESRD 2. Primarily limited by availability of kidneys 3. Many persons on waiting list for kidney 4. Improves survival and quality of life for ESRD client

f.

Organ Donors 1. Majority are from cadavers 2. Transplants from living donors increasing 3. Close match between blood and tissue type desired; HLA are compared; 6 in common is perfect match 4. Living donors must be in good physical health; nephrectomy is major surgery and remaining kidney must be healthy c. Cadaver donors 1. Cadaver kidney from persons who a. Meets criteria for brain death b. Are aged < 65 years old c. Are free of systemic disease, malignancy, or infection including HIV, hepatitis B, C 2. Kidney removed and preserved by hypothermia a. Transplant in 24 48 hours b. Use technique: continuous hypothermic pulsatile perfusion, and transplant up to 3 days 3. Donor kidney placed in lower abdominal cavity, renal artery, vein, and ureter are anastomosed d. Immunosuppressive therapy 1. Necessary to block immune response that would reject transplanted organ 2. Medications include a. Glucocorticoids: prednisone and methylprednisolone used for maintenance and treatment of acute rejection episodes b. Azathioprine: inhibits cellular and humoral immunity; metabolized by liver c. Mycophenolate mofetil: more potent and minimal bone marrow suppression d. Cyclosporine: affects cellular immunity; is hepatotoxic and nephrotoxic e. Rejection 1. Can occur at any time 2. Acute rejection a. Occurs within months of transplant b. Cellular immune response with T cells c. Few manifestations 1. Rise in serum creatinine 2. Possibly oliguria d. Treatment 1. Methylprednisolone 2. OKT3 monoclonal antibody 3. Chronic rejection a. Develops months to years post transplant b. Major cause of graft loss c. Involves both humoral and cellular immune response d. Manifestations (same as renal failure) 1. Progressive azotemia 2. Proteinuria 3. Hypertension f. Complications of kidney transplant 1. Hypertension 2. Glomerular lesions with manifestations of nephrosis 3. Increased risk for myocardial infarction and stroke g. Complications associated with long-term immunosuppression 1. Infection: bacterial, viral, fungal in blood, lung, CNS 2. Tumors: carcinoma in situ in cervix, lymphomas, skin cancers 3. Steroid use leads to bone problems, peptic ulcer disease, cataract formation 11. Health Promotion a. Ensure all clients with impaired renal function are well hydrated, especially while receiving nephrotoxic drugs b. Encourage clients with ESRD to explore transplant options 12. Nursing Diagnoses a. Impaired Tissue Perfusion: renal b. Imbalanced Nutrition: Less than body requirements c. Risk for Infection d. Disturbed Body Image 13. Home Care a. CRF and ESRD are long-term processes requiring client management b. Extensive teaching required 1. Monitoring health status 2. Compliance with fluid and dietary restriction and medications 3. Care involved with hemodialysis, peritoneal dialysis, or living with transplant

b.