Renal NURS 2016 Chapters: 44, 45

Urolithiasis Nephrolithiasis vs urolithiasis Factors favouring stone formation: Infections Infections Urinary stasis Urinary stasis Periods of immobility Periods of immobility Altered calcium metabolism Altered calcium metabolismCauses: Conditions that promote increased Calcium in blood & urine Conditions that promote increased Calcium in blood & urine

Clinical Manifestations Obstruction Obstruction Infection Infection Edema Edema

Nursing Assessment Pain: severity & location Pain: severity & location Signs of UTI Signs of UTI Signs of obstruction Signs of obstruction Stones in urine Stones in urine

Interventions Pain Opiates & NSAID Opiates & NSAID Hot baths, moist heat Hot baths, moist heat Fluid intake encouraged Fluid intake encouragedNutrition Fluids to ensure > 2L urine/day Fluids to ensure > 2L urine/day Protein < 60 mg/day Protein < 60 mg/day

Nursing Diagnoses  Acute pain, as evidenced by complaints, facial grimicing and restlessness, related to irritation of stone and inadequate pain control or comfort measures  Anxiety, as evidenced by expressions of concern about future treatments, related to uncertain outcome and lack of knowledge regarding possible surgery.  Ineffective therapeutic regime management, as evidenced by questions that indicate inadequate knowledge of disorder, related to lack of knowledge about prevention of recurrence, diet, fluid requirements, and symptoms of recurrence.  Impaired urinary elimination, as evidenced by decrease in urinary output and blood urine, related to …  Risk of infection, related to …

Education High fluid intake (drink in evening & night) High fluid intake (drink in evening & night) Discourage excessive intake of vitamins & minerals Discourage excessive intake of vitamins & minerals Urine culture every 1-2 months Urine culture every 1-2 months Avoid excessive sweating & dehydration Avoid excessive sweating & dehydration Avoid sudden increase in environments temperature signs & symptoms of stone formation, obstruction, S&S infection Avoid sudden increase in environments temperature signs & symptoms of stone formation, obstruction, S&S infection

Infections of the Urinary Tract Lower UTI Cystitis: inflammation of the urinary bladder Cystitis: inflammation of the urinary bladder Prostatitis: inflammation of the prostate Prostatitis: inflammation of the prostate Urethritis: inflammation of the urethra Urethritis: inflammation of the urethra Upper UTI Acute & chronic pyelonephitis: inflammation of the renal pelvis Acute & chronic pyelonephitis: inflammation of the renal pelvis Interstitial Nephritis: inflammation of the kidneys Interstitial Nephritis: inflammation of the kidneys

Urinary Tract Infection LowerUpper Pain, burningFever FrequencyChills UrgencyFlank or lower back pain NocturiaNausea & vomiting IncontinenceHeadache & malaise DysuriaSupra pubic, back or Hematuria pelvic pain

Treatment & Prevention Pharmacology Septra, Bactrim, Azithromycin (Zithromax) Septra, Bactrim, Azithromycin (Zithromax) Nitrofurantoin NitrofurantoinHygiene Voiding habits Voiding habits Fluid intake

Neurogenic Bladder Spastic (reflex) Upper motor neuron lesion Upper motor neuron lesion Loss of conscious sensation & cerebral motor control Loss of conscious sensation & cerebral motor controlFlaccid Lower motor neuron lesion Lower motor neuron lesion Bladder fills, distends, overflows Bladder fills, distends, overflows

Management Goals Prevent over distention of bladder Prevent over distention of bladder Empty bladder regularly & completely Empty bladder regularly & completely Maintain sterility of urinary system Maintain sterility of urinary system Maintain adequate bladder capacity without reflux Maintain adequate bladder capacity without reflux Urecholine Urecholine

Catheterization Continuous Continuous Intermittent Intermittent Suprapubic Suprapubic

Nephrostomy Tube Temporary or permanent urinary diversion Temporary or permanent urinary diversion Inserted through skin & into renal pelvis Inserted through skin & into renal pelvis Prophylactic antibiotic Prophylactic antibiotic

Care of Nephrostomy Tube Assess possible complications Assess possible complications Ensure unobstructed drainage Ensure unobstructed drainage Notify surgeon immediately if tube dislodges Notify surgeon immediately if tube dislodges Never clamp Never clamp Never irrigate Never irrigate Encourage fluid intake Encourage fluid intake Measure & record I & O accurately Measure & record I & O accurately

Renal Failure Renal Failure Systemic disease Systemic disease Kidneys unable to remove body’s metabolic wastes Kidneys unable to remove body’s metabolic wastes Progressive & irreversible Progressive & irreversible

Clinical Manifestations Cardiovascular Cardiovascular Integumentary Integumentary Pulmonary Pulmonary Gastrointestinal Gastrointestinal Neurological Musculosketal Neurological Musculosketal Reproductive Reproductive Hematologic Hematologic

Stages Reduced renal reserve Reduced renal reserve 40-70% loss of nephron function 40-70% loss of nephron function asymptomatic asymptomatic Renal insufficiency Renal insufficiency 75-90% loss of nephron function 75-90% loss of nephron function Increased creatinine & BUN – polyuri, nocturia Increased creatinine & BUN – polyuri, nocturia End stage renal disease End stage renal disease Less than 10% nephron function Less than 10% nephron function Uremia Uremia

Management Pharmacological Pharmacological Dialysis Dialysis Diet Diet

Dialysis Dialysis cleans the blood, either by passing it through an artificial kidney machine or by filtering it within the abdomen. Wastes & excess water are removed during treatment Dialysis cleans the blood, either by passing it through an artificial kidney machine or by filtering it within the abdomen. Wastes & excess water are removed during treatment Hemodialysis most common blood is pumped through a dialyzer Hemodialysis most common blood is pumped through a dialyzer Peritoneal dialysis the peritoneal cavity is filled with dialysate Peritoneal dialysis the peritoneal cavity is filled with dialysate

Clinical Case 48 year old husband, father Acute kidney failure – progressed to chronic Hemodialysis started 1 wk ago (3x/wk) c/o weakness, dry skin, nausea Dependent edema, tenacious sputum, serum K+high Quiet, moody

Planning Care: Mind Mapping Octogon: assessment data Oval: nursing diagnosis Triangle: expected outcome Rectangle: nursing intervention