3Anatomy System includes the kidneys and entire urinary tract 2 kidneys located behind the peritoneum, on either side of the spineWeighs about 8 oz and the left if longer and narrower than the right
4Kidney Renal capsule- fibrous tissue Renal cortex- outer tissue Medulla-inner tissue with “fans”Pyramids-12-18/kidneyPapilla-end of the pyramidCalyx-collects the urine at the end of the papillaRenal pelvis- calices form it and leads to ureter
5Renal blood flow Kidneys receive 20-25% of the total cardiac output Blood flow is ml/minRenal artery comes off of the abdominal aortaExits off the renal vein and into the IVC
6Nephrons Functioning unit of the kidney Urine is formed from blood 1 million nephronsBlood comes from the afferent arterioles, enters the glomerulusLeaves by efferent arterioles
7Nephron parts Bowman’s capsule surrounds the glomerulus Proximal convoluted tubuleLoop of HenleDistal convoluted tubuleCollecting ducts
8Renin-angiotensin system Renin is produced by the macula densa cells note changes in the distal convoluted tubulesBased on decreased BP, bld volume and bld NA levelsRenin changes angiotensinogen into angiotensin I, ACE changes it to angiotensin II
9Angiotensin II Leads to 4 main outcomes: Increased Na concentration (aldosterone from adrenal cortex)Increased serum Na level by tubular reabsorption of Na in ascending loop of Henle (constricts afferent arteriole to decrease GFR, if bld volume is low)Allows fluid to be removed and increases Na concentration in the bld, if blood volume if normal (constricts efferent arteriole to increase GFR)Enhances reabsorption of Na from DCT
10Renal regulatory functions Glomerular filtration- water, electrolytes, Cr, urea N and glucose are filteredBlood, albuminis too largeForms 180 L of filtrate/day or GFR=125ml/minRegulated by constricting and dilating the afferent arterioleWhen SBP goes below 70mm Hg, GFR stops (MAP of 60)
11Tubular reabsorption and Secretion Most of the water and electrolytes are reabsorbed, 65% of filtrate to keep urine output at 1-3 LMost of water reabsorption is in the PCT, some is in DCTDCT is affected by ADH and aldosteroneADH enhances water reabsorption by increasing membrane permeabilityAldosterone reabsorbs NaSolute Reabsorption50% of urea, no creatinineMost Na, Cl is reabsorbed in the PCT, some in the collecting ducts by aldosteroneK is reabsorbed in the PCT and the ascending loop of HenleBicarb, Ca and Phosphate are in the PCTGlucose is reabsorbed up to 220mg/dl > will be excretedTubular secretion is substance need to be excreted, such as K and H
12Renal hormones Renin= RAAS (renin-angiotensin-aldosterone system) Prostaglandins- PGE and PGI, regulate filtration and vascular resistanceBradykinins-dilates the afferent arteriole and increase capillary membrane permeabilityErythropoetin-released when there is decreased oxygen, triggers RBC production in the bone marrowVitamin D activation- converted to its active form in the kidney
13Renal Assessment Personal history- what questions should we ask? What about diet, why is that important?What is a normal urine output?What types of medical conditions can affect the kidneys?
14Renal AssessmentInspection- note any swelling or discoloration in the flank region, costovertebral angle is 12th rib and vertebraeAuscultate for what?How do you palpate the kidneys?, not be done is suspect pheochromocytoma, what is that?Percuss what? Only the kidneys or bladder too?
15Diagnostic tests Urine Blood Urinalysis for inspection, odor, cloudiness, pH, specific gravityWhat is a normal S.G.?What things would be abnormal in the urine?How high is the bacterial count in order to be treated?BloodCreatinine- end product of muscle and protein metabolism ( )BUN- excretion of urea N from protein metab, liver failure, trauma will elevate (10-20 mg/dlRatio BUN/CR is 12-20:1, dehydration can cause BUN to be elevated, but not CRDecreased ratio will occur with FVE
16Diagnostic tests IVP- intravenous pyelogram, now called IV urography Given a contrast dye, should not give if pt has renal insufficiencyShows the size, shape and location of kidneysPatency of calices, pelves and uretersDetects obstructions and masses
17Diagnostic TestsCT of the kidneyRenal Arteriogram
18Diagnostic Renal Biopsy Check blood counts before procedure, may need to transfuseGiven procedural sedationMonitor the site for bleeding 24 hours after, bruising on flank, H&HBedrest for 6 hoursWill have hematuria
19CystoscopyVisualize the bladder and any abnormalities
20Urinary Tract Infections UTI’s are the most prevalent nosocomial infections, costing 1.6 billion/yrHow can they be prevented in the hospital?What is the recommended length of time a catheter should remain in, in the acute care setting?What factors may contribute to a UTI?Which organisms are most commonly the cause of UTI’s?
21Urinary Tract Infections Cystitis- inflammation of the bladder, interstitial cystitis, unknown etiologyCan lead to urosepsis, has a high mortality and prolonged hospitalizationIncidence is greater in women than men and increases by 50% in women over 80
22Case Study- UTI24 y.o. sexually active female, who arrives in the ED, complaining of frequency, urgency and dysuria. She has difficulty initiating a stream. This has been occurring for the past 3 days, but not she feels weak and has noticed some blood in her urine
23Case Study What type of questions may you ask this patient? What type of urine sample would you get?The urine comes back with > 100,000 c./mlShould this be treated? What is the most common antibiotic that is given for an uncomplicated 3 day course?
24Case StudyWhat nursing diagnoses would be appropriate for this patient?What patient education should be done?Include diet and prevention therapy
25Urinary Incontinence Incontinence- involuntary loss of urine Not a normal result of agingIn the elderly, can be caused by:Medications, disease, depression, unable to walk or get to the BR
26Types of incontinenceStress- most common, occurs during coughing, sneezing, jogging or lifting, weakening of the bladder neck can occur with childbirth, can’t tighten the urethra enough to overcome the urge to voidUrge- when they feel the “urge” to go, they can not hold it until they find a BR, called overactive bladder, can be caused by CVA, parkinson’s disease, MS, UTI, BPH, artificial sweeteners, caffeine, alcohol, diruetics, nicotine
27IncontinenceOverflow- when the detrusor muscle fails to contract, the bladder becomes overdistended, leaks out to prevent rupture, may be urethral obstruction, diabetic neuropathy, pelvic surgeryReflex- abnormal detrusor contractions r/t neurologic problems- CVA, spinal cord lesions, MSFunctional- loss of cognitive function in patients with dementia
28Incontinence 85% of all cases are women Contributing factors are: Medications- diuretics, opioidsDiseases- CVA, arthritis, parkinson’sPsychological disturbancesPhysical examinationAssess for bladder fullness- bladder scan, cystocele, note detrusor muscle
29Incontinence- Interventions Exercise- kegel’s strengthen pelvic floorWeight reduction, decrease fluids at nightDrug therapy- estrogen, antispasmodics- ditropan, probanthine, bentyl, detrol, antidepressants- tricyclics- anticholinergics and alpha-adrenergics, so decrease urinationVaginal cone- weighted cones to tighten muscles, pessary to hold bladder up in cases of cystocele
30Incontinence- Surgery Vaginal or retropubic surgeryElevates the urethra, repairs cystocelePostop- monitor voiding, may have SP catheter, PVR should be less than 50ml, monitor for bleeding
31Incontinence education What type of education should be provided for bladder training?How can you get the family to help?If the patient does need to straight cath or have a foley at home, what things should they monitor for?
32Renal Calculi- Urolithiasis Nephrolithiasis- stones in the kidneyUreterolithiasis- stones in the ureter75% of the stones contain Ca- Ca oxalate or Ca phosphate15% struvite, 8% uric acid and 3% cystine90% of patient have a metabolic risk factor for the stonesIncidence is higher in men
33Renal calculi Formation is from Slow urine flow from the element, such as CaDamage to the lining of the tractDecreased inhibitor substances in the urine that would dissolve
34Renal Calculi Risk Factors Hypercalcemia-Increased intake or renal failureHyperparathyroidismImmobilizationHyperoxaluria-genetic trait that overproducesExcess intake from spinach, rhubarb, coca, beets, wheat germ, pecans, okra, chocolateHyperuricemia-Gout with purine metabolism disorderIncreased purines from cancers and thiazide diureticsStruvite-Magnesium ammonium phosphate and carbonate, urea splitting bacteria causesCystinuria-Genetic defect of amino acids
35Renal Calculi Symptoms: Interventions: Renal colic- what is that?Oliguria vs anuria, what is the difference?What is the predominant nursing diagnosis?Interventions:Drug therapy:Pain relief, what should be used?Besides opioids, what medication may be helpful?Lithotripsy-Shock wave therapy to break up stonesMonitor ECG, bleeding afterStrain the urine for stone collection
36Surgical interventions Nephrolithotomy and ureterolithotomyEndoscope or lithotriptor to grasp and extract the stoneNephrostomy tube is left in placeKeep the nephrostomy site sterile and never irrigate with more than 10 mlMay be performed as an open procedure if the stone is too large
37Patient education How can the patient prevent getting more stones? What foods should be avoided if the patient has a calcium oxalate stone? A calcium phosphate stone? A struvite stone? A uric acid stone?How much fluid should the patient take in per day?
38Renal DisordersPolycystic kidney disease- genetic disorder, cysts develop on the kidney, most patients are hypertensive, RAAS is activatedAs the patient ages, kidney is more damagedControlled by monitoring the BP and using ACE inhibitors, control the cell proliferation of PKD, follow a low NA dietControl for pain, many need a transplant
40Glomerulonephritis Third leading cause of ESRD Disorders that cause are often autoimmune, such as:Lupus, Goodpasture’s syndrome, Wegener’s granulomatosis, amyloidosis, diabetes, HIV, hepatitis C, cirrhosis, sickle cell disease, endocarditisInfectious processes also cause, such as:Beta-hemolytic streptococcus, Staph bacteremia, syphilis, pneumococcal mycoplasma or klebsiella, CMV, histoplasmosis, varicella, toxoplasmosis
41Glomerulonephritis An infection may precipitate Symptoms occur 10 days 75% of patients have edema of face, hands, eyelidsFluid overload and circulatory congestion
42GlomerulonephritisUrine is smoky or reddish brown with hematuria and oliguriaHTN with wt. gainFatigue, anorexia, N&VWhat kind of labs would be done?What lab would be done to assess for a strep infection?What type of 24 hour urine would be done?
43Case Study- Nephrotic Syndrome 8 y.o. presents to the hospital with swelling of the face and hands. He has the sickle cell trait. His mother has noted a marked decrease in his urine output and it looks dark brown. He complains of feeling tired and not wanting to eat.
44Case Study What process occurs with Nephrotic syndrome? What would you expect to see in his urine? What about his lab values?His mother asks if this condition can be cured, what would you say?What type of treatment may be prescribed? Medications and therapy
45Benign Prostatic Hypertrophy Prostate become hyperplastic and enlarges with ageProstate extends upward into the bladder and inward, narrowing the urethral channelObstructs urine flow, overflow incontinenceBladder becomes irritable and leads to urgency and frequency, muscles enlarge and can lead to hydroureters and hydronephrosis
46BPH Symptoms: Assessment: What nursing diagnoses would be appropriate? NocturiaFrequency, urgencyReduced stream and forceIncomplete emptying and dribblingHematuria in elderly malesAssessment:Digital rectal examUrinalysisPSA level, what is this for?What nursing diagnoses would be appropriate?
47BPHMedications:Shrink- Proscar, finasteride, lowers DHT, may take 6 months to lower, major side effect is ED and decreased libidoAlpha-adrenergic blockers- Hytrin, Cardura, Flomax, constricts the prostrate and reduces pressureAvoid medications that may cause urinary retention, such as anticholinergics, antihistamines and decongestantsDon’t take in a large amounts of fluid, avoid alcohol and diuretics, that can cause overdistention
48BPH Surgery TURP- transurethral resection of the prostate Can only remove pieces of the prostrate in chip formSuprapubic, Retropubic and Perineal prostatectomy- done when the prostate is large or the bladder also needs to be explored
49BPH surgery Postop: Assess incision site if applicable for bleeding Continuous Bladder irrigation (CBI) done 24 hours post surgeryMonitor for FVE, running total of I & OBleeding is to be expected, but urine should not be “frank” blood, may have clots, monitor H&HMay have bladder spasms, ditropan or B&O supp.
50Renal FailureRenal failure is the loss of function r/t nephron damage. In CRF, 90-95% of the nephrons are lost before failure is obviousARF, only 50% decrease in nephrons can cause failure, ARF is a sudden onset and may last < 3 mo, good prognosisMost common causes of CRF are:Diabetes (43%), HTN (25%), glomerulonephritis (8%)
51Acute Renal failure- ARF Types of ARF:Prerenal azotemia- correct by increasing BP, giving volume, improve C.O., prolonged damage can lead to intrarenal failureIntrarenal- ATN- infections, drugs, NSAID’s, aminoglycosides, tumors, glomerulonephritis
52Phases of ARF Onset: Oliguric: Hours to days, precipitating event until oliguria, BUN and Cr increaseOliguric:Urine output of ml/day, does not respond to diuretics or fluid challenges, BUN and CR increase, K, Magnesium and Phosphate increase, Na is retained, but masked with fluid, dilutional, lasts 8-15 days
53Phases of ARF Diuretic: Recovery: Urine output increases rapidly, can be 10L/day of dilute urine, electrolyte losses occur, BUN decreases last, 2-6 weeks, until BUN falls, renal tubular function returnsRecovery:Functions at lower level, may take up to 12 months to return to normalIn critically ill patients, 50-80% mortality rate for those who develop ATN
54Case Study for ARF25 y.o. male admitted to the ICU post MVA, he had multiple fractures, ruptured spleen and significant blood loss. He has been in the ICU for 24 hours and is ventilated. He has received blood transfusions and maintenance IV fluids, but his blood pressure continues to drop and is presently 80/44, his urine output has only been 100 ml for the past 12 hours.What do you expect is occurring?
55Case Study for ARFWhat type of ARF is the patient experiencing? What phase is he in?What can be done to initially correct this problem?What nursing interventions should be done to monitor for patient improvement?The MD says that the patient has prerenal azotemia, what does that mean?
56Case Study- ARFIf the patient is in the oliguric phase, what would the lab values be?CR –Bun –Na –K –Phosphorus-Ca –Magnesium –Bicarbonate-pH-
57Case Study- ARFBecause of the disruption in electrolytes, what symptoms may the patient experience?Besides electrolytes, what other labs should the RN monitor?K-Na-Phosphate-Ca-H-
58Case Study- ARF What are the main Nursing diagnoses for this patient? What medications may be given to this patient?Besides replacements, what other meds would be needed?What should his diet include?How much protein can he take in?How much fluid?
59Case Study- ARFThe patient remains oliguric and has persistent hyperkalemia, FVE and metabolic acidosis, the MD decides that he must begin dialysis to remove the end-productsCRRT is ordered, what does this mean? Why is this done instead of Hemodialysis?What type of catheter would be inserted? Where is the cath inserted?Why not have a renal fistula done?
60Case Study- ARF Prisma machine used for CRRT Can do hemofiltration, uses a double venous access, one catheter is arterial and one venous returnChanges in fluid removal can be set for every minutes and so they don’t remove as much as regular hemodialysisSet blood flow at 150ml/hr, dialysate rate at 1L/hr
61Case Study- ARFAfter 5 days on CRRT, the patient’s kidneys begin to improve and his urine output is >30ml/hr, his BP has stabilized and he is off of all vasopressors. He is being transferred to the floor.What types of things should be still be careful of? What agents may be nephrotoxic to him?
62Chronic Renal Failure Progressive, irreversible kidney disease Kidney function does not recover, ESRDHave azotemia (increased nitrogen wastes), uremia (azotemia with symptoms), uremic syndrome (clinical and labs r/t ESRD)
63Chronic Renal Failure Stages of CRF: Stage 1: Diminished Renal Reserve- renal function is reduced, but no accumulation of wastes, can’t concentrate urinepolyuria and nocturiaStage 2: Renal Insufficiency- wastes accumulate, no response to diuretics, oliguria and edema develop, decreased GFRStage 3: ESRD- excessive wastes, BUN and CR, H, treatment is dialysis
64Chronic Renal Failure Metabolic changes: BUN, CR elevated Na elevated in later stages, may appear nl or low at firstK elevated, up to 7 or 8 mEq/L, can cause cardiac arrestH is elevated metabolic acidosis, lungs try to blow off Kussmaul’s respirationsCa is low, phosphorus is elevated stimulation of PTH, which causes Ca to be released form bone renal osteodystrophy, lack of vitamin D also makes it worse
65Chronic Renal Failure Cardiac changes: Hematologic: GI changes: Hypertension- most have because of what?Hyperlipidemia- changes fat metabolism elevated trigylcerides, cholesterol and LDLHeart failure- resulting from increased cardiac workload r/t volume, HTN and CADUremic pericarditis- pericardial sac becomes inflammed with toxins pericardial effusion, tamponade and deathHematologic:Anemia occurs because of decreased erythropoetin and RBC’sGI changes:Ammonia from urea breakdown causes halitosis and stomatitisAnorexia, N & V occurs, PUD may occur
66Chronic Renal Failure Clinical Signs: Clinical Signs: Neurologic Lethargy, seizures, coma from uremiaCardiovascularTachycardia, increased BP, elevated CVP, peripheral edemaRespiratoryTachypnea, kussmaul’sClinical Signs:HematologicAnemia, bleeding, fatigueGIAbdominal pain, anorexia, foul breathUrinaryOliguria, proteinuria, hematuria, amount depends on dialysisSkinYellowish tint, pruitus, uremic frost, purpura and ecchymosis
67Chronic Renal FailureWhat are the common nursing diagnoses for the patient with CRF?
68Chronic Renal Failure- Interventions Diet therapy:Increase calories, but restrict Protein, Fluid, K, Na, Phosphorus, why restrict protein? If the patient is on peritoneal dialysis, protein may be increasedTake vitamins and minerals- return vitamin D, Ca, folic acid
69Chronic Renal Failure- Interventions Drug therapy-Diuretics- only if FVE that is not on dialysisBiologic response modifiers- procritPhosphate binders- amphojel, alternagel, renagel, tums, oscalStool softeners- colace, miralaxVitamins- folic acid, ferrous sulfateAntihypertensives- ACE, Ca channel and betas may be used
70Renal Replacement Therapies HemodialysisBetter clearanceShort time for treatmentHave to leave home 3x/wkCan cause disequilibrium syndrome, muscle cramps, hemorrhageRestricted dietPeritoneal dialysisEasy accessFewer hemodynamic complicationsInfections and adhesions can occurLess effectiveProtein loss and peritonitisUses intra-abdominal catheter
71Hemodialysis Used in patients with: Fluid overload Pericarditis Uncontrolled HTNUremic signsWorsening anemiaIrreversible renal failure when other therapies are not possible
72Hemodialysis Process: Diffusion of molecules with the use of dialysate solution, high in electrolytes, waterWaste products move from the blood through the filters semipermeable membrane into the outflow resevoirWater is also removed by osmosis as it follows the solutes
73Hemodialysis Hemo filter- over 1 million fine hairs, act as nephrons Venous accessAV shunt- only short termCan become dislodged, or bleed
74Hemodialysis Venous access AV fistula or graft- artery and vein anastomosed, as it matures, blood flow increases and it enlargesDo not take BP or blood draws from that armAssess pulsesPalpate for thrill and listen for bruitsNo lifting of heavy objects
75Hemodialysis CareWeigh the patient before and after, know the “dry wt”Measure BP, HR and RespirationsWatch for orthostatic hypotensionWatch for disequilibrium syndrome- after HD is completed, change in fluid and urea headache, N&V, change in LOC, cerebral edema, seizures, slowing down the fluid removal can prevent itBleeding can occur, from heparinization of the lines and low blood countsInfectious diseases, such as hepatitis C and HIV through blood transmission
76Peritoneal dialysisSilastic Catheter is inserted in the abdominal cavityDialysate is inserted, dwells for 3-4 hours, allowing fluid to mix with dialysateEffluent or outflow is then opened and waste products and water are removed
77Peritoneal dialysis Process is by diffusion and osmosis of products Dialysate has water and electrolytes, also glucose in 2.5, 5 or 10%, determines the amount of diffusionHeparin and antibiotics may be added to dialysateCan be done either throughout the day with a Y-set or at night with an automatic cycler
78Peritoneal dialysis Tenckhoff, peritoneal catheter Complications Peritonitis- contamination of catheter, cloudy outflow, fever, abdominal pain and crampingPainPoor outflow and leakage- can be caused by constipation, fibrin clots in the catheter
79Renal Transplantation Selection:Free from medical problems, such as cancer, heart disease and diabetes ( should be under control)Age is 2-70Use living and cadaver donors
80Renal Transplantation Postoperative CareMonitor urine output, should return to normal in 48 hours, color may be pink with some clotsComplications:RejectionHyperacute- within 48 hours, fever, pain and increased BPAcute- 1 wk to 2 yrs, most common, oliguria, fever, enlarged kidney, elevated BUN, CrChronic- months to years, gradual increase in BUN, Cr, fluid retention, fatigue
81Renal Transplantation ComplicationsATN- may have occurred due to damage to transplanted kidneyThrombosis- renal artery or vein 2-3 days postRenal artery stenosis- may lead to hypertension, can often be repaired with a stentInfections- on immunosuppressives for lifeCyclosporine, prednisone, imuran