The Urinary System and Dialysis

Kidney Blood Flow

Kidneys Role is to maintain body fluid volume and composition, filter waste products for elimination. Regulate blood pressure Participate in acid-base balance Produce erythropoietin for RBC synthesis Metabolize vitamin D to an active form

Kidneys Regulatory functions: Control fluid, electrolyte and acid base balance Hormonal functions: Control red blood cell formation, blood pressure and vitamin D activation

Hormonal Renin Prostaglandins Bradykinin Erythropoietin Vitamin D activation

Ureters Each kidney has a single ureter-connects renal pelvis with urinary bladder. ½ inch diameter 12 to 18 inches in length

Urethra Narrow tube- mucous membranes and epithelial cells Men- 6 to 10 inches Women- 1 to 1.5 inches Tube for eliminating urine from the body. Urination removes bacteria from the urethra.

Renal changes in older adult Changes occur as part of the aging process. Kidney smaller by 80 yr/old Function decreases with aging. Decreased bladder capacity Reduced ability to retain urine.

Patient history Family history for risk Personal history- age, previous renal problems, prescription drugs, OTC’s, work exposure Diet history- intake or appetite changes Changes in urination pattern or continence

Physical assessment Inspection Auscultation Palpation Percussion

Lab tests Serum creatinine Blood urea nitrogen Urine culture and sensitivity 24 hr urine Urine- Creatinine clearance

UA Strip

Urinalysis Color, odor, turbidity Specific gravity pH Glucose Ketones Protein Leukoesterase Nitrites Sediment

Radiology Kidney, Ureter, Bladder x-rays Intravenous urography (IVP) CT, US VCUG Renal scan Cystoscopy

IVP

Renal biopsy Determine cause for renal dysfunction and direct treatment Percutaneous with US or CT Monitor for bleeding, vital signs, hematuria, increasing pain or discomfort Bed rest 2-6hrs

Urolithiasis Calculi in the urinary tract Nephrolithiasis- stones in the kidney Ureterolithiasis- stones in the ureter Hypercalcemia Hyperoxaluria Hyperuricemia Struvite cystinuria

Kidney Stones

Physical assessment Renal colic Pain most intense when stone moving or ureter obstructed Nausea, vomiting, pallor, diaphoresis Obstruction is emergency KUB or CT to determine

Interventions PAIN RELIEF Lithotripsy Hydration Strain urine-to determine cause of stone Surgical- if too large Stent Percutaneous nephrolithotomy

Lithotripsy

Chronic renal failure Progressive, irreversible kidney injury No return of kidney function ESRD- kidney function too poor to sustain life Stage I- diminished renal reserve Stage II- renal insufficiency Stage III- end stage renal disease

Body changes Elevates blood pressure Increased triglycerides, total cholesterol and LDL levels Heart failure Anemia GI upset

Patient education for prevention Observe for changes in urine- color, amount, discomfort Adequate amount of fluids Know family history Control DM, HTN Take medication as prescribed

Interventions Nutrition therapy Protein restriction Sodium restriction Potassium restriction Vitamin supplementation Drug therapy Fluid restriction Dialysis

Hemo vs peritoneal dialysis More efficient clearance Shorter treatment time Muscle cramps Hemodynamic changes Vascular access route Specially trained nurses Vascular access care Restricted diet Easy access Few hemodynamic complications Hyperglycemia Bowel perforation Peritoneal adhesions Intra-abdominal catheter Simple Less complex training More flexible diet

HD system Dialyzer Dialysate Vascular access route HD machine Anticoagulation

Types of access for HD AV fistula AV graft Tunneled catheter Hemo catheter AV shunt Subcutaneous device

Care of the access NO !!!! Blood pressure readings, venipunctures or IV lines in extremity with access Assess for bruit and thrill frequently Evaluate extremity for CMS and ROM No heavy lifting with accessed arm Observe for infection

Care of HD patient May hold medications until after treatment Monitor for side effects of treatment Weigh before and after treatment Assess access before and after treatment Observe access for bleeding after treatment

Peritoneal dialysis Occurs in the peritoneal cavity Slower than HD- more time needed for same effect For hemodynamically unstable and cannot tolerate anticoagulation Not if pt. has abdominal adhesions or extensive intra-abdominal surgery

Diffusion and osmosis across semipermeable membrane and capillaries. Solutes and water move from area of higher concentration in the blood to an area of lower concentration in the dialyzing fluid (diffusion) Dialysate prescribed based on patient's fluid status Heparin to tube to prevent clotting Potassium and antibiotics in Dialysate

Care of PD patient Mask self and patient Sterile gloves Observe Dialysate for color Frequent vital signs Weigh before and after treatment Strict I/O

Kidney Transplant

Kidney transplant Treatment for ESRD Candidates selected based on medical problems and risks Donors- living related, living non-related, cadaveric Immunosupressive medications long term

Post operative Ongoing physical and renal assessment I/O strict Complications: Rejection Thrombosis Infection Urinary tract complication

Rejection Hyperacute: Within 48 hrs of surgery Increased temp Increased BP Immediate removal of kidney

Acute rejection: 1wk to 2 yr Oliguria or anuria Temp over 100F Increased BP Elevated creat, BUN, K+ Increased doses of immunosuppressive drugs

Chronic rejection: Gradual over months to years Fluid retention Changes in electrolytes Conservative treatment until dialysis needed

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