1
Q
what is the purpose of the renal system?
A
- Maintain fluid and electrolyte homeostasis
- Excrete urine
- Buffering system to control pH
2
Q
what is the renal system critical to the production of?
A
- Synthesize vitamin D to active form (necessary for
maintaining blood calcium balance - Hormone that stimulates red blood cells (erythropoietin)
- Hormone that regulate blood pressure (renin)
- Activate growth hormone
- Secrete prostaglandins
3
Q
absence of urine
A
anuria
4
Q
an increase in the volume of urine
A
diuresis
5
Q
painful urination
A
dysuria
6
Q
involuntary nocturnal urination
A
enuresis
7
Q
when the pt voids more frequently than what is usual for the pt
A
frequency
8
Q
inflammation of the kidney
A
nephritis
9
Q
blood in the urine
A
hematuria
10
Q
difficulty initiating urination
A
hesitancy
11
Q
the inability of control urination or defecation
A
incontinence
12
Q
means the presence or formation of stones
A
lithiasis
13
Q
excessive urination at night
A
nocturia
14
Q
a decrease in the formation or passing of urine
A
oliguria
15
Q
the passing of an abnormally large amount of urine
A
polyuria
16
Q
the presence of an abnormally large amount of protein in the urine
A
proteinuria
17
Q
the presence of an abnormal amount of white blood cells in the urine
A
pyuria
18
Q
the inability of the pt to empty their bladder
A
urinary retention
19
Q
an intense desire to urinate immediately
A
urgency
20
Q
what are the factors that promote proper renal and urinary function?
A
- Adequate flow of blood to and from the kidney- good blood pressure,
sufficient volume (intake of fluids) - Functioning filtering system: nephrons, afferent (to) and efferent
(from) arterioles supply and flow - Patent ducts from kidney (ureter) and from bladder
- Intact bladder (no holes, tears)
- Proper nerve innovation and info relay (hormones)
- Functioning pelvic floor muscles ( and spincter function
- Proper pH
21
Q
- A waste product that comes from the normal wear and tear on muscles of the body.
- Creatinine levels in the blood can vary depending on age, race and body size.
- Higher than normal levels may be an early sign that the kidneys are not working properly.
- As kidney disease progresses, the level of creatinine in the blood rises. 53–106 mcmol/L (men)
44–97 mcmol/L (women).
A
serum creatinine
22
Q
- Comes from the breakdown of protein in the foods you eat.
- A normal BUN level is between 6–25, with 15.5 being the best value.
- As kidney function decreases, the BUN level rises.
- Common medications, including large doses of aspirin and some types of antibiotics, can also increase
your BUN
A
blood urea nitrogen
23
Q
- measures of how well the kidneys are removing wastes and excess fluid from the blood.
- It is calculated from the serum creatinine level using age and gender with adjustment for those of
African American descent. - The normal value for GFR is 90 or above.
- A GFR below 60 is a sign that the kidneys are not working properly.
- Once the GFR decreases below 15, one is at high risk for needing treatment for kidney failure, such as
dialysis or a kidney transplant.
A
estimated glomerular filtration rate
24
Q
A 24-hour urine test shows how much urine your kidneys produce
can give an more accurate measurement of how well your kidney are working and
how much protein leaks from the kidney into the urine in one day.
compares the creatinine in a 24-hour sample of urine to the creatinine level in
your blood to show how much waste products the kidneys are filtering out each
minute
A
creatinine clearance test
25
Includes microscopic examination of a urine sample as well as a dipstick test.
The dipstick is a chemically treated strip, which is dipped into a urine sample.
The strip changes color in the presence of abnormalities such as excess amounts
of protein, blood, pus, bacteria and sugar.
A urinalysis can help to detect a variety of kidney and urinary tract disorders,
including chronic kidney disease, diabetes, bladder infections and kidney stones.
urinalysis (R&M)
26
* Affect upper and lower urinary tract
* Inflammation of urinary tract, usually by bacterial infection (E. coli)
* Classified as: Complicated or uncomplicated; initial or recurrent;
unresolved or bacterial persistence
urinary tract infection
27
what are the lower UTI emptying symptoms?
weak urinary system
hesitancy
intermittency
postvoid dribbling
urinary retention or incomplete emptying dysuria
28
difficulty starting the urine stream resulting in a
delay between initiation of urination by relaxation of the urethral
sphincter and when urine stream actually begins
hesitancy
29
interruption of the urinary stream
intermittency
30
urine loss after completion of voiding
postvoid dribbling
31
inability to empty
urine from the bladder, which can be caused by atonic bladder or
obstruction of the urethra. Can be acute or chronic
urinary retention or incomplete emptying
32
difficulty voiding; pain on urination
dysuria
33
what are the lower UTI storage symptoms?
urinary frequency
urgency
incontinence
nocturia
nocturnal enuresis
34
what are the gerontologic considerations and UTIs?
* High incidence of chronic illness
* Frequent use of antimicrobials
* Presence of infected pressure ulcers
* Immunocompromised
* Cognitive impairment
* Immobility and incomplete emptying of bladder
* Use of bedpan rather than toilet
35
Inflammation of the urinary bladder
* Bacteria can invade the bladder from an infection in the
kidneys, lymphatics and urethra
* Causes include urologic invasive procedures, fecal
contamination, prostatitis or BPH, pregnancy & sexual
intercourse (honeymoon cystitis)
cystitis
36
what are the S&S of cystitis?
* Urgency
* Frequency
* Low back pain
* Dysuria
* Perineal and suprapubic pain
* Hematuria
* May experience fever and chills
* Urinalysis reveals increase in WBC and RBC
* C&S will identify organism
37
what is the medical management of cystitis?
* Antimicrobial therapy (e.g., Septra)
* Cranberry juice and vitamin C recommended to
keep bacteria from adhering to bladder wall
38
what is the nursing care for cystits?
* CNI
* Encourage extra fluids (at least 8 large glasses with at least one glass
of cranberry juice) excluding coffee, tea, alcohol, & colas- UT irritants
* Emphasize the importance of finishing prescribed course of
medication
* Instruct client on preventive measures
* Void at regular 2-3h intervals & after sexual intercourse
* Shower rather than tub bathe
* Clean perineum with front to back motion
* Wear cotton underwear
* Avoid irritating substances (e.g., bubble bath, vaginal sprays)
39
* Inflammation of the urethra
* More commonly seen in men than women
* If caused by organisms other than gonococci – non-gonococcal
urethritis
* Gonorrhea attacks urethral mucous membranes
* Women: may accompany cystitis or result from a vaginal infection or
soaps, sanitary napkins or scented toilet tissue
* Men: Chlamydia, trauma or instrumentation, rectal intercourse or
intercourse with a woman with vaginal infection
* Discomfort during urination & frequency
* Fever not common
* In male may be due to spread of infection to the prostate or testes
urethritis
40
what is the medical management of urethritis?
* Antibiotic therapy
* Increased fluid intake (water, cranberry juice)
* Avoid fluids which are UT irritants
* Analgesics
* Warm sitz baths
* Good diet and plenty of rest
* If STI, prompt treatment
41
what is the nursing care for urethritis?
* CNI
* Reinforce the importance of receiving and completing prescribed
treatment
* Encourage fluids
* Warm sitz baths/analgesics for pain
* Preventive measures
* Sterile/gentle technique with catheterization
* Frequent perineal care (especially if incontinent)
* Client and family teaching re: causes & prevention
* E.g., hygiene; use of condom/abstinence to prevent spread of
infection; avoid irritants
42
* Chronic, painful inflammatory disease of the bladder wall that
causes disintegration of the lining and loss of bladder elasticity
* Believed to be associated with an autoimmune or allergic
response
interstitial cystitis
43
what are the clinical manifestations of interstitial cystitis?
* Pain and UTI’s are clinical manifestations
* Pain is suprapubic, or entire perineal region.
* Pain relieved by urination
44
what is the collaborative care of interstitial cysitis?
* Dietary and lifestyle changes
* Medications to control symptoms
* Reassurance
45
* Inflammation of the renal pelvis, tubules and collecting system of one
or both kidneys.
* Normal fecal flora such as E. coli (85%) and Staph aureus are
common causes
pyelonephritis (upper UTI)
46
results from active bacterial infection causing kidneys to
enlarge and develop abscesses. Prompt dx and Rx required to
prevent septic shock and death from urosepsis
* Urosepsis – systemic infection from a urological soursce
acute pyelonephritis
47
results from repeat or continued upper UTI
* Chronic usually associated with anatomic UT anomaly, obstruction, or
vesicoureteral reflux (repeated or continued upper UTI)
chronic pylonephritis
48
what are the clinical manifestations of acute pyelonephritis?
* Kidneys inflamed &
enlarged/abscesses
* Flank pain/tender
costovertebral angle (CVA)
* Colicky abdominal discomfort
* Chills, fever and malaise-
systemically ill
* Frequency, urgency and burning
on urination if also have cystitis
* Urine cloudy/foul odor
* Leukocytosis
* pyuria
49
what are the clinical manifestations of chronic pyelonephritis?
* Irreversible damage occurs; renal
dysfunction may not occur for 20
years or more. Eventual
development of chronic renal
insufficiency.
* Asymptomatic or may have low
grade fever, vague GI complaints,
increased BP
* Polyuria/nocturnal when tubules
fail to reabsorb water efficiently
50
what is the medical surgical management of acute pylonephritis?
* Ensure adequate fluid intake
* Avoid caffeine, alcohol, citrus juices,
chocolate and spiced foods or
beverages (irritant)
* Management of the pain and fever
(apply heat)
* Antibiotics x 14 days (common for UTI:
Septra, Cipro – can persist for 6 wks)
* Stress importance of taking full
course
* Antispasmodics and anticholinergics
* Follow-up urine cultures 2 wk post
treatment
51
what are the medical surgical management of chronic pyelonephritis?
* Aim is to prevent further kidney
damage
* Surgery (nephrectomy) if severe
hypertension develops & other
kidney has adequate function
* End stage renal disease
52
what is the nursing care of acute/chronic pyelonephritis?
* Monitor vital signs and urine
characteristics ....note pyuria
* Check blood work- serum
creatinine & blood urea nitrogen
(BUN), electrolytes; urine for C&S
* I&O; Encourage fluid intake 2000-
3000 mls daily
* Encourage client to drink cranberry
juice
* Take all medications as prescribed
* Follow up: check BP
* Avoid alcohol, coffee, tea, cola if
bladder spasms
* Monitor for sudden onset of
confusion, especially in elderly
* Preventative measures: Void q 2-3
hr. when awake and before &
after intercourse; wipe front to
back; wear cotton underwear;
avoid irritating bath gels, etc.
53
what is the prevention of pyelonephritis?
* Prevention: avoid indwelling catheters; exercise proper care of
catheters
* Exercise correct personal hygiene
* Take medications as prescribed: antibiotics, analgesics, and
antispasmodics
* Apply heat to the perineum to relieve pain and spasms
* Increase fluid intake
* Avoid urinary tract irritants such as coffee, tea, citrus, spices, cola,
and alcohol
* Frequent voiding
54
what is the cause of transient incontinence?
Delirium, Infection of UT, Pharmacologic, Psychological, Excessive urine
production; restricted Activity, Stool Impaction (DIAPPERS)
55
* Involuntary loss of urine due to sudden increase in intra-
abdominal pressure i.e. coughing, lifting, straining.
* Commonly affects women who have had vaginal deliveries
stress incontinence
56
* Involuntary loss of urine associated with strong urge to
void that cannot be suppressed (preceded by warning in
advance)
* Can occur in pt. with neurologic dysfunction that impairs
inhibition of bladder contraction or in pt. without overt
neuro dysfunction
urge incontinence
57
* Involuntary loss of urine due to hyperreflexia in absence
of normal sensations usually associated with voiding
* Spinal cord injuries
* No warning or stress precedes periodic involuntary
urinaiton
reflex incontinence
58
* Involuntary loss of urine due to “outside” factors – ex.
Medications (Alpha blockers for BP – blocks alpha
receptors responsible for bladder neck closing pressure–
side effect is incontinence. Med is stopped and
symptoms resolve.)
iatrogenic incontinence
59
* Lower urinary tract function is intact but other factors (ex.
Severe cognitive impairment) make it difficult for pt. to
identify need to void
functional incontinence
60
* The inability to urinate or effectively empty the bladder
* Acute or Chronic
* Acute: usually cannot void at all
* Chronic: cannot completely empty the bladder (retention with
overflow)
* a large volume of residual urine
urinary retention
61
s seen with complete urethral obstruction, after general
anesthetic, epidural anesthetic, post gyne/bladder surgery, childbirth,
or the administration of certain drugs
acute urinary retention
62
is seen with disorders such as enlarged prostate or
neurologic disorders resulting in neurogenic bladder (does not get
adequate nerve stimulation)
chronic urinary retention
63
what are the assessment findings for acute and chronic urinary retention?
* Acute
* Sudden inability to void, distended bladder, lower abdominal pain
and discomfort
* Chronic
* May go unnoticed (become accustomed as the bladder has stretched
over time)
* May void frequently in small amounts or dribbling
* May be signs of cystitis: fever, chills, pain on urination
* Increased WBCs in urine
* Important to determine postvoid residual (PVR)
64
what is medical-surgical management for acute and chronic urinary retention?
ACUTE
* Immediate catheterization
* Intermittent (in and out)
* Indwelling
* May need instruments to
dilate urethra
CHRONIC
* Permanent drainage with a
urethral catheter or a
suprapubic cystostomy
* Clean intermittent
catheterization (CIC)
(preferred method)
* Condom catheter for men
* Crede voiding (applying
downward pressure to bladder
during voiding)
* Valsalva voiding (bear down
with defecation;
contraindicated in some
clients)
65
what is the nursing care for acute urinary retention?
* Conscious client will be able to
verbalize discomfort of urinary
retention; some others will not (e.g.,
Alzheimer’s)
* I&O, monitor voiding pattern ** (8 hrs
post-op)
* Palpate gently for a distended bladder
* Collaborate with physician regarding
catheterization (indwelling or
intermittent and type, size)
* Catheterized q 4-6h depending on
volume obtained
* If more than 400 mL should be
catheterized more often
* Bladder overdistention leads to loss
of tone
66
what is the nursing care for chronic urinary retention?
* Assessment (voiding frequency, pain,
etc.)
* Intermittent catheterization
* Indwelling
catheter-urethral/suprapubic
* Encourage fluid intake (2000-3000 mL)
unless contraindicated
* Especially those that acidify urine
e.g., cranberry juice
* Emotional support/teaching
* Hygiene, perineal care, signs of UTI
* Self-catheterization
* Catheter care, taping, drainage
bag below bladder level, ensure no
kinking
67
formation of a kidney stone in the urinary tract
nephrolithiasis
68
a stone within the ureter
ureterolithiasis
69
what are the predisposing factors of kidney and ureteral stones?
calciuria, dehydration, alkaline urine,
obstructive disorders causing urinary stasis, osteoporosis,
prolonged immobility, gout (uric acid crystallizes in urine)
70
* A calculus is a precipitate of mineral salts
* 70-80% are mainly calcium-calciuria, excessive calcium in the
urine, is a predisposing factor (immobility, water supply,
excessive intake of vit D)
kidney/ureteral stones
71
what are the 5 categories of stones?
Calcium phosphate, Calcium oxalate, uric acid, cysteine and
struvite (mg-ammonium phosphate)
72
what are the clinical manifestations of kidney and ureteral stones?
* Symptoms vary with size, location and cause of calculi
* Usually sudden, sharp, severe flank pain radiating to the
suprapubic area and external genitalia- classic symptom
* Accompanied by renal or ureteral colic-”worst pain known to
man”
* Pain severity inversely proportional to stone size
* The pain causes nausea, vomiting & shock
* Urinary retention or dysuria (if obstructed)
73
what is the nursing care for kidney and ureteral stones?
* Assess/relieve pain, nausea & vomiting
* Monitor levels of BUN, creatinine, electrolytes
* Encourage ambulation & fluid intake (2000-2200 mL/day)
* I&O; strain urine; check for hematuria, anuria (if bilaterally
obstructed)
* Encourage to void q 2-3 hrs/maintain patency of
catheters/nephrostomy tubes
* Strict asepsis to prevent microbes entering urinary tract
* Emotional support & teaching
* Avoid excessive milk intake, increase acid forming foods
74
* Most common malignant tumor of the urinary tract is
transitional cell carcinoma of the bladder
* Affects more men than women
* Chronic recurrent stones (often bladder) and chronic lower
urinary tract infections increase risk.
bladder cancer
75
what are the risk factors of bladder cancer?
* Cigarette smoking
* Exposure to environmental
carcinogens
* Recurrent UTI’s
* Bladder stones
* High urinary ph
* High cholesterol intake
* Pelvic radiation
* Cancer of prostate, colon and
rectum in males
76
what are the clinical manifestations of bladder cancer?
* Gross, painless but visible
hematuria (chronic or
intermittent); most common
* Bladder irritability with dysuria,
frequency and urgency
* Change in urinary pattern
* Pelvic or back pain if metastasis
* Dx: urine specimens for cytology,
confirmed with cystoscopy and
biopsy.
77
what is the medical management of bladder cancer?
* Transurethral resection,
cystoscopy
* Pharmacologic:
* Opioid analgesics
* stool softeners.
* Chemotherapy (combo- with
methotrexate, BCG)
* Radiation (reduce
microextension of tumor)
78
what is the nursing care of bladder cancer?
* Pre and Post op care: expected
changes in urine color
* Quit smoking, avoid alcohol
* Assess for UTI (Apply CNI for UTI)
* Stress routine urological follow-ups
* 15- to 20-minute sitz bath two to
three times a day to promote
muscle relaxation and to reduce
the risk of urinary retention
* Listen to and provide education for
fears and concerns
79
(not technically a diversion device):
keeping drainage bag lower than bladder, choose right size
of catheter, lubricant, insert far enough to prevent trauma,
avoid manipulation (traumatize the urethra and bacteria
invade)
urinary catheter
80
client ability to void is tested once
obstruction resolved; clamped until can void, then removed
suprapubic catheter
81
tube from kidney to outside abdomen
nephrostomy tube
82
implanting ureter into 12-cm loop of ileum to
abdominal surface with attached urostomy bag, stents
placed in ureters to prevent occlusion (care like any ostomy)
ileoconduit
83
involves inability of nephrons in kidneys to
maintain fluid, electrolyte and acid-base balances, remove
nitrogenous waste products and perform regulatory
functions
Develops as a consequence of various factors such as
decreased blood flow, conditions which damage nephrons
and obstructive disorders
renal failure
84
what are the 2 types of renal failure
acute
chronic
85
* Complex disorder with many etiological factors and variant clinical
manifestations
* Develops as a consequence of:
* prerenal (e.g., hypovolemic shock, decreased CO)
* intrarenal (e.g., nephrotoxicity, lupus)
* postrenal (e.g., enlarged prostrate, stones) disorders (Chart 45-2 pg.
1413)
* Rapid accumulation of toxic wastes occurs (azotemia)
* serum urea (BUN) and creatinine (CR) levels rise;
* BUN accumulates when protein is broken down; CR is a waste product of
the muscles
* Serum creatinine (CR) good indicator of kidney function
* Client becomes oliguric and treatment directed towards correcting
cause and preventing permanent damage
acute renal failure
86
what are the 4 stages of acute renal failure?
initiation or onset
maintenance
recovery
prevention
87
Once acute kidney injury occurs S&S appear
within hrs/days (initiation)
initiation or onset
88
Accompanied by a reduced blood flow to kidney leading to
acute tubular necrosis (death of cells in collecting tubules of nephrons), CR,
UR, K, MG
oliguric-anuric
89
gradual increase in U/O glomerular filtration has started to recover -
lots of fluid loss but remain uremic
diuresis
90
what is medical management of acute renal failure?
* IV therapy
* Hemodialysis
* Peritoneal dialysis
* Fluid and dietary restrictions
complex/individualized and
depend on use of dialysis
(low/high protein, low Na & K,
phosphorus, increased Ca,
decreased fat if
hyperlipidemia)
* Correct anemia (iron/vit
supplements)
91
what are potential nursing diagnoses?
excess fluid volume
imbalanced nutrition
risk for impaired skin integrity
activity intolerance
risk for infection
risk for electrolyte imbalances
risk for ineffective coping
92
* The kidneys are so badly damaged that they do not adequately:
* remove protein by-products and electrolytes from the blood,
* maintain acid-base balance
* perform regulatory functions such as maintaining calcification of bones and
producing erythropoietin (needed for RBC production).
* Classified into 5 stages (table 49-6)
* Renal insufficiency stage occurs when 75% of nephron function is lost
* End-stage renal disease (ESRD) when 85-90% of nephrons are lost
(stage 5)
chronic renal failure
93
* Procedure for cleaning and filtering the blood
* Provides a substitute for kidney function when the kidneys
are unable to remove waste products, maintain fluid
electrolyte and acid-base balances
dialysis
94
what are the 2 types of dialysis?
hemodialysis
peritoneal dialysis
95
requires transporting blood from the client through
a dialyzer, a semipermeable membrane filter within a machine
hemodialysis
96
uses the peritoneum, the semipermeable
membrane lining the abdomen, to filter wastes, fluid and
chemicals
peritoneal dialysis
97
what are the complications of peritoneal dialysis?
* Exit-site infection
* Peritonitis
* Abdominal pain
* Outflow problems
* Hernias
* Lower back problems
* Bleeding
* Pulmonary complications
* Protein loss
* Carbohydrate and lipid abnormalities
98
what are the complications of hemodialysis?
hypotension
dysrhythmias
muscle cramps
loss of blood
hepatitis
sepsis
disequilibrium syndrome
99
what is the nursing care for dialysis?
* Nursing assessment – fluid status (? Weight, BP, peripheral edema,
heart and lung sounds)
* Assess condition of vascular access
* Temperature
* Skin condition
* Fluid gained since last treatment
* Vital signs every 30-60 mins
* What to do if hypotensive? (elevate feet)
* Treatment lasts 3-5 hours min 3 times a week
