Urinary System

Urinary Tract Calculi Ambulation Prevention of further stone development Patient and family history Geographic residence Nutritional assessment Activity patterns Immobilization or dehydration Indications for endourologic stone removal, lithotripsy, or open surgical stone removal include Stones too large for passage Association with bacteriuria Causing impairment in renal function Causing persistent pain, nausea, or paralytic ileus Nursing implementation Teach methods to prevent recurrence Change of lifestyle and dietary habits Adequate fluid intake: to produce approximately 2 L of urine per day Dietary restriction (e.g., purines) Low Na diet Evaluation Maintain free flow of urine with minimal hematuria Report satisfactory pain relief Verbalize understanding of disease process and measures to prevent recurrence

Acute Kidney Injury

Acute kidney injury (AKI), previously known as acute kidney failure, is the term used to encompass the entire range of the syndrome, including a very slight deterioration in kidney function to severe impairment. AKI is characterized by a rapid loss of kidney function. This loss is accompanied by a rise in serum creatinine level and/or a reduction in urine output. The severity of dysfunction can range from a small increase in serum creatinine or reduction in urine output to the development of azotemia (an accumulation of nitrogenous waste products [urea nitrogen, creatinine] in the blood). AKI can develop over hours or days with progressive elevations of blood urea nitrogen (BUN), creatinine, and potassium, with or without a reduction in urine output. Etiology and Pathophysiology Phases of ARF Oliguria Phase Diuretic Phase Recovery Phase ** If a patient does not recover from AKI it can progress to CKD Clinical Manifestations Oliguric phase Urinary changes Urinary output less than 400 mL/day Occurs within 1 to 7 days after injury Lasts 10 to 14 days Urinalysis may show casts, RBCs, WBCs Waste product accumulation Elevated BUN and serum creatinine levels Neurologic disorders Fatigue and difficulty concentrating Seizures, stupor, coma Fluid volume With decreased urine output, fluid retention occurs Neck veins distended Bounding pulse Edema Hypertension Fluid overload can lead to heart failure, pulmonary edema, and pericardial and pleural effusions Metabolic acidosis Serum bicarbonate level decreases Severe acidosis develops Kussmaul respirations Sodium balance Increased excretion of sodium Hyponatremia can lead to cerebral edema Potassium excess Usually asymptomatic ECG changes Diuretic phase Daily urine output is 1 to 3 L May reach 5 L or more Monitor for hyponatremia, hypokalemia, and dehydration Recovery phase May take up to 12 months for kidney function to stabilize Q&A: Which assessment would indicate to the nurse that a patient has oliguria related to an intrarenal acute kidney injury? a) Urinary sodium levels are low.b) The serum creatinine level is normal.c) Oliguria is relieved after fluid replacement. d) Urine testing reveals a specific gravity of 1.010. Rationale: The urine specific gravity in oliguria of intrarenal acute kidney injury will be fixed at 1.010. This value reflects tubular damage with loss of concentrating ability by the kidneys. The serum creatinine level is above normal in oliguria of intrarenal acute kidney injury. Urinary secretion of sodium increases with oliguria of intrarenal acute kidney injury. Prerenal oliguria related to hypovolemia will usually respond to fluid replacement. Diagnostic studies Thorough history Serum creatinine Urinalysis Kidney ultrasonography Renal scan Computed tomography (CT) scan Renal biopsy Contraindicated Magnetic resonance imaging (MRI) Magnetic resonance angiography (MRA) with gadolinium contrast medium Nephrogenic systemic fibrosis Contrast-induced nephropathy (CIN) Collaborative care Primary goals Eliminate the cause Manage signs and symptoms Prevent complications Ensure adequate intravascular volume and cardiac output Closely monitor fluid intake during oliguric phase Hyperkalemia Insulin and sodium bicarbonate Calcium carbonate Sodium polystyrene sulfonate (Kayexalate) Indications for renal replacement therapy (RRT) Volume overload Elevated serum potassium level Metabolic acidosis BUN level higher than 120 mg/dL (43mmol/L) Significant change in mental status Pericarditis, pericardial effusion, or cardiac tamponade Renal replacement therapy (RRT) Peritoneal dialysis (PD) Intermittent hemodialysis (HD) Continuous renal replacement therapy (CRRT) Cannulation of artery and vein Nursing Management Planning The patient with AKI will Completely recover without any loss of kidney function Maintain normal fluid and electrolyte balance Have decreased anxiety Comply with and understand the need for careful follow-up care Nursing implementation Monitor intake and output Monitor electrolyte balance Measure daily weight Replace significant fluid losses Use nephrotoxic drugs sparingly Evaluation The expected outcomes are that the patient with AKI will Regain and maintain normal fluid and electrolyte balance Comply with the treatment regimen Experience no untoward complications Have complete recovery Gerontologic Considerations More susceptible to AKI Polypharmacy Hypotension Diuretic therapy Aminoglycoside therapy Obstructive disorders Surgery Infection

ADDITIONAL ELECTROLYTE DISTURBANCES WITH CRD

Dialysis Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure Treat drug overdoses Begun when patients uremia can no longer be adequately managed conservatively Initiated when GFR (or creatinine clearance) is less than 15 mL/min Dialysis Two methods of dialysis available Peritoneal dialysis (PD) Hemodialysis (HD) ESKD treated with dialysis because There is a lack of donated organs Some patients are physically or mentally unsuitable for transplantation Some patients do not want transplants Osmosis and Diffusion across Semipermeable Membrane Peritoneal Dialysis Peritoneal access is obtained by inserting a catheter through the anterior abdominal wall Technique for catheter placement varies Usually done via surgery Tenckhoff Catheter Waiting period of 7 to 14 days preferable Two to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness Once site healed, patient may shower and pat dry Dialysis Solutions and Cycles Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25% Electrolyte composition similar to that of plasma Solution warmed to body temperature Three phases of PD cycle Inflow (fill) Dwell (equilibration) Drain Called an exchange Inflow Prescribed amount of solution infused through established catheter over about 10 minutes After solution infused, inflow clamp closed to prevent air from entering tubing Dwell Also known as equilibration Diffusion and osmosis occur between patients blood and peritoneal cavity Duration of time varies, depending on method Drain Lasts 15 to 30 minutes May be facilitated by gently massaging abdomen or changing position Complications Exit site infection Peritonitis Hernias Lower back problems Bleeding Pulmonary complications Protein loss Effectiveness and Adaptation Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD Hemodialysis Obtaining vascular access is one of most difficult problems Types of access Arteriovenous fistulas and grafts Temporary vascular access Vascular Access for Hemodialysis Dialyzers Long plastic cartridges that contain thousands of parallel hollow tubes or fibers Fibers are semipermeable membranes Hemodialysis Procedure Two needles placed in fistula or graft One needle is placed to pull blood from the circulation to the HD machine The other needle is used to return the dialyzed blood to the patient Components of Hemodialysis Continual Renal Replacement Therapy (CRRT) Alternative or adjunctive method for treating AKI Means by which uremic toxins and fluids are removed Acid-base status/electrolyte balance adjusted slowly and continuously Often used in hemodynamically unstable patients Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow Specimens may be obtained for evaluation Most common approaches: venovenous Continuous venovenous hemofiltration (CVVH) Continuous venovenous hemodialysis (CVVHD) Q&A: A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patients diet?a) Fatb) Proteinc) Caloriesd) Carbohydrates

Kidney Transplantation Very successful One-year graft survival rate Cadaver transplants: 90% Live donor transplants: 95% Advantages of kidney transplantation over dialysis Reverses many of the pathophysiologic changes associated with renal failure Eliminates dependence on dialysis Less expensive than dialysis after the first year Kidney Transplantation Immunosuppressive Therapy Goals Adequately suppress the immune response Maintain sufficient immunity to prevent overwhelming infection Complications Rejection Acute rejection Occurs days to months after transplantation Chronic rejection Process that occurs over months or years and is irreversible Infection CV Disease Malignancies Recurrance of Renal Disease Steriod-Related Complications Q&A: Six days after kidney transplantation from a deceased donor, a patient develops a temperature of 101.2 F (38.5 C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicatea) Acute rejection, which is not uncommon and is usually reversible.b) Hyperacute rejection, which will necessitate removal of the transplanted kidney.c) An infection of the kidney, which can be treated with IV antibiotics.d) The onset of chronic rejection of the kidney with eventual failure of the kidney.

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