Renal and Urinary Disorders.pdf

RENAL AND URINARY DISORDERS DIAGNOSTIC TESTS LABORATORY STUDIES Common laboratory studies pertaining to renal and urologic disorders include blood and urinary excretion tests for renal function, prostate-specific antigen (PSA), and urinalysis. Tests of Renal Function D...

RENAL AND URINARY DISORDERS DIAGNOSTIC TESTS LABORATORY STUDIES Common laboratory studies pertaining to renal and urologic disorders include blood and urinary excretion tests for renal function, prostate-specific antigen (PSA), and urinalysis. Tests of Renal Function Description  Renal function tests are used to determine effectiveness of the kidneys' excretory functioning, to evaluate the severity of kidney disease, and to follow the patient's progress.  There is no single test of renal function; best results are obtained by combining a number of clinical tests.  Renal function is variable from time to time. Nursing and Patient Care Considerations Renal function may be within normal limits until about 50% of renal function has been lost. Tests of Renal Function There is no single test of renal function because this function is subject to variation. The rate of change of renal function is more important than the result of a single test. Test Purpose/Rationale Test protocol Renal concentration test  Tests the ability to  Fluids may be concentrate solutes in the withheld 12-24 hours  Specific gravity urine. to evaluate the  Osmolality of  Concentration ability is lost concentrating ability urine early in kidney disease; of the tubules under hence, this test detects early controlled conditions. defects in renal function. Specific gravity measurements of urine are taken at specific times to determine urine concentration. Creatinine clearance  Provides a reasonable  Collect all urine over approximation of rate of 24-hour period. glomerular filtration.  Draw one sample of  Measures volume of blood blood within the cleared of creatinine in 1 period. minute.  Most sensitive indication of early renal disease. 1   Useful to follow progress of the patient's renal status. Serum creatinine  A test of renal function  Obtain sample of reflecting the balance blood serum. between production and filtration by renal glomerulus.  Most sensitive test of renal function. Serum urea nitrogen  Serves as index of renal  Obtain sample of (Blood urea nitrogen excretory capacity. blood serum. [BUN])  Serum urea nitrogen depends on the body's urea production and on urine flow. (Urea is the nitrogenous end-product of protein metabolism.)  Affected by protein intake, tissue breakdown. Protein  Random specimen may be  Collect all urine over affected by dietary protein 24-hour period. intake. Proteinuria >150 mg/24 hours may indicate renal disease. Microalbumin/Creatinine  Sensitive test for the  Collect random urine ratio subsequent development of specimen. proteinuria; >30 mcg/mg creatinine predicts early nephropathy. Urine casts  Mucoproteins and other  Collect random urine substances present in renal specimen. inflammation; help to identify type of renal disease (eg, red cell casts present in glomerulonephritis, fatty casts in nephrotic syndrome, white cell casts in pyelonephritis). Prostate-Specific Antigen Description 2   PSA is an amino acid glycoprotein that is measured in the serum by a simple blood test.  An elevated PSA indicates the presence of prostate disease, but is not exclusive to prostate cancer.  Level rises continuously with the growth of prostate cancer.  Normal serum PSA level is less than 4 ng/mL. Levels less than 10 ng/mL may be indicative of benign prostatic hyperplasia (BPH) and not necessarily prostate cancer.  Patients who have undergone treatment for prostate cancer are monitored periodically with PSA levels for recurrence. Nursing and Patient Care Considerations  No patient preparation is necessary.  Some clinicians prefer not to perform digital rectal examinations of the prostate at the same time that a PSA is drawn, to prevent artificial elevation of PSA level, although this association has not been proved.  Clinical laboratories may differ slightly in methods used for determining PSA; patients having serial PSA should be sent to the same laboratory. Urinalysis Description Involves examination of the urine for overall characteristics, including appearance, pH, specific gravity, and osmolality as well as microscopic evaluation for the presence of normal and abnormal cells.  Appearance: normal urine is clear. o Cloudy urine (phosphaturia) is not always pathologic, related only to the precipitation of phosphates in alkaline urine. Normal urine may also develop cloudiness on refrigeration or from standing at room temperature. o Abnormally cloudy urine due to pus (pyuria), blood, epithelial cells, bacteria, fat, colloidal particles, phosphate, or lymph fluid (chyluria).  Odour: normal urine has a faint aromatic odor. o Characteristic odours produced by ingestion of asparagus, thymol. o Cloudy urine with ammonia odour: urea-splitting bacteria such as Proteus, causing UTIs. o Offensive odour may be due to bacterial action in presence of pus.  Colour: shows degree of concentration and depends on amount voided. o Normal urine is clear yellow or amber because of the pigment urochrome. o Dilute urine is straw-coloured. o Concentrated urine is highly coloured; a sign of insufficient fluid intake. o Cloudy or smoky coloured may be from haematuria, spermatozoa, prostatic fluid, fat droplets, chyle. o Red or red-brown due to blood pigments, porphyria, transfusion reaction, bleeding lesions in urogenital tract, some drugs and food (beets). o Yellow-brown or green-brown may reveal obstructive lesion of bile duct system or obstructive jaundice. o Dark brown or black due to malignant melanoma, leukemia. 3   pH of urine: reflects the ability of kidney to maintain normal hydrogen ion concentration in plasma and extracellular fluid; indicates acidity or alkalinity of urine. o pH should be measured in fresh urine because the breakdown of urine to ammonia causes urine to become alkaline. o Normal pH is around 6 (acid); may normally vary from 4.6 to 7.5. o Urine acidity or alkalinity has relatively little clinical significance unless the patient is on a special diet or therapeutic program or is being treated for renal calculous disease.  Specific gravity: reflects the kidney's ability to concentrate or dilute urine; may reflect degree of hydration or dehydration. o Normal specific gravity ranges from 1.005 to 1.025. o Specific gravity is fixed at 1.010 in chronic renal failure. o In a person eating a normal diet, inability to concentrate or dilute urine indicates disease.  Osmolality is an indication of the amount of osmotically active particles in urine (number of particles per unit volume of water). It is similar to specific gravity, but is considered a more precise test; it is also easy only 1 to 2 mL of urine are required. Average value is 300 to 1,090 mOsm/ kg for females; 390 to 1,090 mOsm/kg for males. Nursing and Patient Care Considerations  Freshly voided urine provides the best results for routine urinalysis; some tests may require first morning specimen.  Obtain sample of about 30 mL.  Urine culture and sensitivity tests are typically performed using the same specimen obtained for urinalysis; therefore, use clean-catch (see Procedure Guidelines 21-1) or catheterization techniques.  Patients with urinary diversions, especially ileal conduit diversions, require special techniques to obtain urine that is not contaminated with bacteria from the intestinal diversion. RADIOLOGY AND IMAGING These tests include simple X-rays, X-rays with the use of contrast media, ultrasound, nuclear scans, and imaging through computed tomography (CT) scanning and magnetic resonance imaging (MRI). X-ray of Kidneys, Ureters, and Bladder Description  Consists of plain film of the abdomen  Delineates size, shape, and position of kidneys  Reveals deviations, such as calcifications (stones), hydronephrosis, cysts, tumors, or kidney displacement Nursing and Patient Care Considerations  No preparation is needed. 4   Usually done before other testing.  Patient will be asked to wear a gown and remove all metal from the X-ray field. Intravenous Pyelogram (Intravenous Urogram) Description  I.V. introduction of a radiopaque contrast medium that concentrates in the urine and thus facilitates visualization of the kidneys, ureter, and bladder.  The contrast medium is cleared from the bloodstream by renal excretion. Nursing and Patient Care Considerations  Contraindicated in patients with renal failure, uncontrolled diabetes, or multiple myeloma.  Contraindicated in patients receiving drug therapy for chronic bronchitis, emphysema, or asthma and in patients taking metformin (Glucophage).  Patients with known iodine/contrast material allergy must have steroid/antihistamine preparation; in some cases, an anesthesiologist must be available.  Bowel preparation is necessary: o Clear liquids only the day before the examination. o Cathartics/laxatives are given the evening before the examination. o Nothing by mouth (NPO) after midnight the day of the examination (if scheduled for afternoon, clear liquids only in the morning). Retrograde Pyelography Description  Injection of opaque material through ureteral catheters, which have been passed up ureters into renal pelvis by means of cystoscopic manipulation. The opaque solution is introduced by gravity or syringe injection.  May be done when intravenous pyelography (IVP) is contraindicated or if IVP provides inadequate visualization of the collecting system. Nursing and Patient Care Considerations Contraindicated in patients with UTI, or with suspected perforation of the ureter or bladder; allergic reactions to contrast material are rare in this examination. Cystourethrogram Description  Visualization of urethra and bladder by X-ray after retrograde instillation of contrast material through a catheter. An examination of only the bladder is a cystogram; of only the urethra is a urethrogram.  Used to identify injuries, tumors, or structural abnormalities of the urethra or bladder; or to evaluate emptying problems or incontinence (voiding cystourethrogram). Nursing and Patient Care Considerations 5   Carries risk of infection due to instrumentation.  Allergy to contrast material is not a contraindication.  Additional X-rays may be taken after catheter is removed and patient voids (voiding cystourethrogram).  Provide reassurance to allay patient's embarrassment. Renal Angiography Description  I.V. catheter is threaded through the femoral and iliac arteries into the aorta or renal artery.  Contrast material is injected to visualize the renal arterial supply.  Evaluates blood flow dynamics, demonstrates abnormal vasculature, and differentiates renal cysts from renal tumors.  May be done to embolize a kidney before nephrectomy for renal tumor. Nursing and Patient Care Considerations  Clear liquids only after midnight before the examination; adequate hydration is essential.  Continue oral medications (special orders needed for diabetic patients).  I.V. required.  May not be done on the same day as other studies requiring barium or contrast material.  Maintain bed rest for 8 hours after the examination, with the leg kept straight on the side used for groin access.  Observe frequently for hematoma or bleeding at access site. Keep sandbag at bedside for use if bleeding occurs. Renal Scans Description  Radiopharmaceuticals (also called radiotracers or isotopes) are injected I.V. o Tc-DTPA or Tc99m-DMSA is used for anatomical visualization and evaluation of glomerular filtration. o Other radiopharmaceuticals may also be used depending on the purpose of the scan.  Evaluates renal size, shape, position, and function or blood flow to the kidneys.  Studies are obtained with a scintillation camera placed posterior to the kidney with the patient in a supine, prone, or sitting position. Nursing and Patient Care Considerations  The patient should be well hydrated. Give several glasses of water or I.V. fluids as ordered before scan.  Furosemide (Lasix) or captopril (Capoten) may be administered in conjunction with the scan to determine their effects. 6 Ultrasound Description  Uses high-frequency sound waves passed into the body and reflected back in varying frequencies based on the composition of soft tissues. Organs in the urinary system create characteristic ultrasonic images that are electronically processed and displayed as an image.  Abnormalities, such as masses, malformations, or obstructions, can be identified; useful in differentiating between solid and fluid-filled masses.  A noninvasive technique. Nursing and Patient Care Considerations  Ultrasound examination of the prostate is performed using a rectal probe. A Fleet enema may be ordered just within hours of the examination.  Ultrasound examination of the bladder requires that the bladder be full.  Patient should not have had any studies using barium for 2 days before ultrasound of the kidney or bladder. Computed Tomography Scanning and Magnetic Resonance Imaging OTHER TESTS Other tests that may be done to evaluate disorders of the renal and urologic systems include cystoscopy, urodynamic testing, and needle biopsy of the kidney. Cystoscopy Description  Cystoscopy is a method of direct visualization of the urethra and bladder by means of a cystoscope that is inserted through the urethra into the bladder. It has a self- contained optical lens system that provides a magnified, illuminated view of the bladder.  Uses include: o To inspect bladder wall directly for tumor, stone, or ulcer and to inspect urethra for abnormalities or to assess degree of prostatic obstruction. o To allow insertion of ureteral catheters for radiographic studies, or before abdominal or GU surgery. o To see configuration and position of ureteral orifices. o To remove calculi from urethra, bladder, and ureter. o To diagnose and treat lesions of bladder, urethra, and prostate. Nursing and Patient Care Considerations  Simple cystoscopy is usually performed in an office setting. More complicated cystoscopy involving resections or ureteral catheter insertions are done in the operating room cystoscopy suite, where I.V. sedation or general anesthesia may be used. 7   The patient's genitalia are cleaned with an antiseptic solution just before the examination. A local topical anesthetic (Xylocaine gel) is instilled into the urethra before insertion of cystoscope.  Because fluid flows continuously through the cystoscope, the patient may feel an urge to urinate during the examination.  Contraindicated in patients with known UTI.  Nursing interventions after cystoscopic examination: o Monitor for complications: urinary retention, urinary tract hemorrhage, infection within prostate or bladder. o Expect the patient to have some burning on voiding, blood-tinged urine, and urinary frequency from trauma to mucous membrane of the urethra. o Administer or teach self-administration of antibiotics prophylactically as ordered to prevent UTI. o Advise warm sitz baths or analgesics, such as ibuprofen or acetaminophen, to relieve discomfort after cystoscopy. Increase hydration. o Provide routine catheter care if urine retention persists and an indwelling catheter is ordered. Urodynamics Description Urodynamics is a term that refers to any of the following tests that provide physiologic and functional information about the lower urinary tract. They measure the ability of the bladder to store and empty urine. Most urodynamic equipment uses computer technology with results visible in real time on a monitor.  Uroflowmetry (flow rate) is a record of the volume of urine passing through the urethra per unit of time (mL/s). It is shown on graph paper and gives information about the rate and flow pattern of urination.  Cystometrograma is recording of the pressures exerted during filling and emptying of the urinary bladder to assess its function. Data about the ability of the bladder to store urine at low pressure and the ability of the bladder to contract appropriately to empty urine are obtained. o One or more small catheters are placed through the urethra (or suprapubic area) into bladder. The residual volume is measured if the patient recently voided, and the catheters are left in place. o The catheters are connected to urodynamic equipment designed to measure pressure at the distal end of the catheter. o Water, saline, or contrast material is infused at a slow rate into the bladder. o When the bladder feels full, the patient is asked to void. A normal detrusor contraction of the bladder appears as a sharp rise in bladder pressure on the graph. If the patient is unable to void, the test may be considered normal because it is difficult to void normally with catheters in place.  Sphincter electromyelography (EMG) measures the activity of the pelvic floor muscles during bladder filling and emptying. EMG activity may be measured using surface (patch) electrodes placed around the anus or with percutaneous wire or needle electrodes.  Pressure-flow studies involve all of the above components, along with the simultaneous measurement of intra-abdominal pressure by way of a small tube with a 8  fluid-filled balloon that is placed in the rectum. This permits better interpretation of actual bladder pressures without the influence of intra-abdominal pressure.  Video urodynamics use all of the above components. The fluid used to fill the bladder is contrast material, and the entire study is performed under fluoroscopy, providing radiographic pictures in combination with the recording of bladder and intra-abdominal pressures. Video urodynamics are reserved for patients with complicated voiding dysfunction. Nursing and Patient Care Considerations  Contraindicated in patients with UTI.  Frequently performed by nurses; essential to provide information and support throughout the test to ensure clinically significant results.  Patients will have burning on urination afterward (due to instrumentation); encourage fluids.  Short-term antibiotics are commonly given to prevent infection. Needle Biopsy of Kidney Description Performed by percutaneous needle biopsy through renal tissue with ultrasound guidance or by open biopsy through a small flank incision; useful in securing specimens for electron and immunofluorescent microscopy to determine diagnosis, treatment, and prognosis of renal disease Nursing and Patient Care Considerations  Prebiopsy nursing management o Ensure that coagulation studies are carried out to identify the patient at risk for postbiopsy bleeding and that serum creatinine, urinalysis, and urine culture are done. o Ensure that patient fasts for several hours before the procedure, as ordered. o Establish an I.V. line, as ordered. o Describe the procedure to the patient, including holding breath (to prevent movement of the thorax) during insertion of the biopsy needle.  Postbiopsy nursing management o Place the patient in a prone position immediately after biopsy and on bed rest for 8 to 24 hours to minimize bleeding. o Take vital signs every 5 to 15 minutes for the first hour and then with decreasing frequency if stable to assess for hemorrhage, which is a major complication. o Watch for rise or fall in blood pressure, anorexia, vomiting, or development of a dull, aching discomfort in abdomen. o Assess for flank pain (usually represents bleeding into the muscle) or colicky pain (clot in the ureter). o Assess for backache, shoulder pain, or dysuria. o Persistent bleeding may be suspected when an enlarging hematoma is palpable through the abdomen. o If perirenal bleeding develops, avoid palpating or manipulating the abdomen after the first examination has determined that a hematoma exists. 9  o Collect serial urine specimens to evaluate for hematuria. o Assess for any patient complaints, especially frequency and urgency on urination. o Keep fluid intake at 3,000 mL daily if tolerated, unless the patient has renal insufficiency. o Check results of hematocrit and hemoglobin (done the following morning) to assess for anemia, unless the vital signs change before then. o Prepare for transfusion and surgical intervention for control of hemorrhage, which may necessitate surgical drainage or nephrectomy.  Instruct the patient on the following after biopsy: o Avoid strenuous activity, strenuous sports, and heavy lifting for at least 2 weeks. o Notify health care provider if any of the following occur: flank pain, hematuria, lightheadedness and fainting, rapid pulse, or any other signs and symptoms of bleeding. o Report for follow-up 1 to 2 months after biopsy; will be checked for hypertension, and the biopsy area is auscultated for a bruit. GENERAL PROCEDURES AND TREATMENT MODALITIES CATHETERIZATION Catheterization may be done to relieve acute or chronic urinary retention, to drain urine preoperatively and postoperatively, to determine the amount of residual urine after voiding, or to determine accurate measurement of urinary drainage in critically ill patients. Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage System Suprapubic catheterization establishes drainage from the bladder by introducing a catheter percutaneously or by an incision through the anterior abdominal wall into the bladder. It may be done for acute urinary retention when urethral catheterization is not possible; for urethral trauma, stricture, or fistula to divert flow of urine from the urethra; or for obtaining an uncontaminated urine specimen for culture. PROCEDURE GUIDELINES Assisting the Patient Undergoing Suprapubic Bladder Drainage (Cystostomy) EQUIPMENT  Sterile suprapubic drainage system package (disposable)  Skin germicide for suprapubic skin preparation; sterile gloves  Local anesthetic agent if needed PROCEDURE Nursing Action Rationale Preparatory phase 1. Place the patient in a supine position with 1. Allows access to suprapubic area but one pillow under head. reduces muscle tension. 2. Expose the abdomen. Performance phase (By physician) 1. The bladder is distended with 300-500 mL 1. Distention of the bladder makes the bladder 10  sterile saline in a urethral catheter, which easier to locate by the suprapubic route. is removed, or the patient is given fluids (PO or I.V.) before the procedure. 2. The suprapubic area is surgically prepared. 2. The needle entry point is in the midline, ¾ After the skin is dried, the needle entry to 1¼ inches (2-3 cm) above the point is located. symphysis pubis and directly over the palpable bladder. 3. The skin and subcutaneous tissues are 3. An adequate level of local anesthesia is infiltrated with local anesthesia. achieved to facilitate catheter introduction. 4. A small stab wound (incision) may be made. 5. The catheter is introduced via a guide 5. Entrance into the bladder is usually felt and wire, needle, or cannula through the can be verified by free flow of urine. incision and advanced in a slightly caudal direction. 6. The catheter is advanced until the flange is 6. Another method is to advance a long needle against the skin where it is secured with into the bladder until urine flow verifies the tape, a body seal system, or sutures. needle is in the bladder. 7. The catheter is connected to a sterile 7. Aseptic technique is used in the area around drainage system. the cystostomy tube. 8. Secure drainage tubing to lateral abdomen 8. Prevents undue tension on the catheter. with tape. 9. If the catheter is not draining properly, 9. Catheter tip may be pinned against the wall withdraw the catheter 1 inch (2.5 cm) at a of the bladder. time until urine begins to flow. Do not dislodge catheter from bladder. 10.The drainage is maintained continuously for several days. 11.If a “trial of voiding†is requested, 11.Usually, patients will void earlier after the catheter is clamped for 4 hours. surgery with suprapubic drainage than with indwelling catheters. a. Have the patient attempt to void while the catheter is clamped. b. After the patient voids, unclamp the b. To determine the effectiveness of catheter and measure residual urine. voiding. c. Usually, if the amount of residual urine is less than 100 mL on two separate occasions (AM and PM), the catheter may be removed. d. If the patient complains of pain or d. To facilitate urinary drainage and prevent discomfort, or if the residual urine is infection due to urinary stasis. over the prescribed amount, the catheter is usually left open. 12.When the catheter is removed, a sterile 12.Suprapubic drainage is considered more dressing is placed over the site. Usually comfortable than an indwelling urethral the tract will close within 48 hours. catheter. It allows greater patient mobility, and there is less risk of bladder infection. 13.Monitor for complications. 13.Complications of this procedure: Inadvertent peritoneal and bowel damage, leakage around catheter, kinking of catheter, 11  hematuria, abdominal wall abscess. DIALYSIS Dialysis refers to the diffusion of solute molecules through a semipermeable membrane, passing from the side of higher concentration to that of lower concentration. The purpose of dialysis is to maintain the life and well-being of the patient. It is a substitute for some kidney excretory functions but does not replace the kidneys' endocrine and metabolic functions. Methods of dialysis include:  Peritoneal dialysis. o Intermittent peritoneal dialysis (acute or chronic) o Continuous ambulatory peritoneal dialysis. o Continuous cycling peritoneal dialysis: it uses automated peritoneal dialysis machine overnight with prolonged dwell time during day.  Hemodialysis  Continuous renal replacement therapy (CRRT): this includes special procedures such as continuous arteriovenous hemofiltration (CAVH), continuous venovenous hemofiltration (CVVH), continuous venovenous hemodiafiltration (CVVHDF), and continuous arteriovenous hemodiafiltration (CAVHD). These use extracorporeal blood circulation through a small-volume, low-resistance filter to provide continuous removal of solutes and fluid in the intensive care setting. o CRRT is indicated for such conditions as acute renal failure, heart failure, pulmonary edema, cerebral edema, anasarca, acute electrolyte disorders, catabolic states, hypotension requiring vasopressor or intra-aortic balloon pump therapy, septic shock, hemodynamic instability, and metabolic crisis. o CRRT may be used when the patient cannot tolerate the hemodynamic and metabolic instability of hemodialysis or has abdominal trauma or scar tissue that prohibits peritoneal dialysis. o CVVH and CVVHDF are accomplished by insertion of a large-gauge double lumen catheter into the internal jugular, subclavian, or femoral vein. A roller- type pump is used to propel blood through the system, and anticoagulation may be used to prevent clotting. o CAVH and CAVHD are accomplished through the insertion of single-lumen catheters into the femoral artery and the femoral vein. Mean arterial pressure must be 60mm Hg or greater to propel blood through the extracorporeal filter. o Care for the patient on CRRT is provided in an intensive care setting, with special attention given to assessment and calculation of fluid and electrolyte balance, aggressive management of hypotension, preventing hemorrhage, monitoring for heat loss through extracorporeal circulation, assessing for infection, and preventing clotting. Peritoneal Dialysis PROCEDURE GUIDELINES Assisting the Patient Undergoing (Acute) Peritoneal Dialysis EQUIPMENT  Dialysis administration set (disposable, closed system)  Peritoneal dialysis solution as requested  Supplemental drugs as requested  Local anesthesia 12   Central venous pressure monitoring equipment  Suture set  Sterile gloves  Skin antiseptic PROCEDURE Nursing Action Rationale Preparatory phase 1. Prepare the patient emotionally and 1. Nursing support is offered by explaining physically for the procedure. procedure mechanics, providing opportunities for the patient to ask questions, allowing verbalization of feelings, and giving expert physical care. 2. See that the consent form has been signed. 3. Weigh the patient before dialysis and 3. The weight at the beginning of the procedure every 24 hours thereafter, preferably serves as a baseline of information. Daily on an in-bed scale. weight confirms ultrafiltration results and evaluates volume status. 4. Take temperature, pulse, respiration, 4. Measurement of vital signs at the beginning of and blood pressure readings before dialysis is necessary for comparing subsequent dialysis. changes in vital signs. 5. Have the patient empty bladder. 5. If the bladder is empty, there is less risk of perforating it when the trocar is introduced into the peritoneum. 6. Flush the tubing with dialysis solution. 6. The tubing is flushed to prevent air from entering the peritoneal cavity. Air causes abdominal discomfort and drainage difficulties. 7. Make the patient comfortable in a 7. This helps protect the patient from airborne supine position. Have the patient and contamination. health care personnel wear masks. Performance phase (By physician) The following is a brief summary of the method of insertion of a temporary peritoneal catheter (done under strict asepsis). 1. The abdomen is prepared surgically, 1. Surgical preparation of the skin minimizes or and the skin and subcutaneous tissues eliminates surface bacteria and decreases the are infiltrated with a local anesthetic. possibility of wound contamination and infection. 2. A small midline stab wound is made -2 inches (5 cm) below the umbilicus. 3. The trocar is inserted through the incision with the stylet in place, or a thin stylet cannula may be inserted percutaneously. 4. The patient is requested to raise head 4. This maneuver tightens the abdominal muscles from the pillow after the trocar is and permits easier penetration of the trocar introduced. without danger of injury to the intra-abdominal organs. 13 5. When the peritoneum is punctured, the 5. This prevents the omentum from adhering to trocar is directed toward the left side of the catheter, impeding its advancement or the pelvis. The stylet is removed, and occluding its opening. the catheter is inserted through the trocar and maneuvered into position. a. Dialysis fluid is allowed to run through the catheter while it is being positioned. 6. After the trocar is removed, the skin 6. The catheter is attached to the skin to prevent may be closed with a purse-string loss of the catheter in the abdomen. suture. (This is not always done.) A sterile dressing is placed around the catheter. 7. Attach the catheter connector to the 7. The solution is warmed to body temperature for administration set, which has been patient comfort and to prevent abdominal pain. previously connected to the container Heating also causes dilatation of the peritoneal of dialysis solution (warmed to body vessels and increases urea clearance. temperature, 98.6° F (37° C). 8. Drugs (heparin, potassium, antibiotic) 8. The addition of heparin prevents fibrin clots are added in advance. from occluding the catheter. Potassium chloride may be added on request unless patient has hyperkalemia. Antibiotics are added for the treatment of peritonitis. 9. Permit the dialyzing solution to flow 9. The inflow solution should flow in a steady unrestricted into the peritoneal cavity stream. If the fluid flows in too slowly, the (usually takes 5-10 minutes for catheter may need to be repositioned because its completion). If the patient experiences tip may be buried in the omentum, or it may be pain, slow down the infusion. occluded by a blood clot. Flushing may help. 10.Allow the fluid to remain in the 10.For potassium, urea, and other waste materials peritoneal cavity for the prescribed to be removed, the solution must remain in the time period (20-30 minutes). Prepare peritoneal cavity for the prescribed time (dwell the next exchange while the fluid is in or equilibration time). The maximum the peritoneal cavity. concentration gradient takes place in the first 5- 10 minutes for small molecules, such as urea and creatinine. 11.Unclamp the outflow tube. Drainage 11.The abdomen is drained by a siphon effect should take approximately 20-30 through the closed system. Gravity drainage minutes, although the time varies with should occur fairly rapidly, and steady streams each patient. of fluid should be observed entering the drainage container. The drainage is usually straw-colored. 12.Check outflow for cloudy appearance, 12.May be an early sign of peritonitis. blood, or fibrin. 13.If the fluid is not draining properly, 13.If the drainage stops, or starts to drip before the move the patient from side to side to dialyzing fluid has run out, the catheter tip may facilitate the removal of peritoneal be buried in the omentum. Rotating the patient drainage. The head of the bed may also may be helpful (or the physician may need to be elevated. reposition the catheter). 14.Ascertain catheter patency. Check for 14.Pushing the catheter in introduces bacteria into closed clamp, kinked tubing, or air the peritoneal cavity. 14  lock. Never push the catheter in. 15.When the outflow drainage ceases to run, clamp off the drainage tube and infuse the next exchange, using strict aseptic technique. 16.Take blood pressure and pulse every 16.A drop in blood pressure may indicate 15 minutes during the first exchange excessive fluid loss from glucose and every hour thereafter. Monitor the concentrations of the dialyzing solutions. heart rate for signs of dysrhythmia. Changes in the vital signs may indicate impending shock or overhydration. 17.Take the patient's temperature every 4 17.An infection is more apt to become evident hours (especially after catheter after dialysis has been discontinued. removal). 18.The procedure is repeated until the 18.The duration of dialysis depends on the severity blood chemistry levels improve. The of the condition and on the size and weight of usual duration for short-term dialysis is the patient. 48 to72 hours. Depending on the patient's condition, 48 to 72 exchanges will be necessary. 19.Keep an exact record of patient's fluid 19.Complications (circulatory collapse, balance during the treatment. hypotension, shock, and death) may occur if the a. Know the status of the patient's loss patient loses too much fluid through peritoneal or gain of fluid at the end of each drainage. Large fluid losses around the catheter exchange. Check dressing for may not be noted unless the dressings are leakage and weight on gram scale if checked carefully. significant. b.The fluid balance should be about even or should show slight fluid loss or gain, depending on the patient's fluid status. 20.Promote patient comfort during 20.The dialysis period is lengthy, and the patient dialysis. becomes fatigued. a. Provide frequent back care and a.Pain may be caused by the dialyzing solution massage pressure areas. not being at body temperature, incomplete drainage of the solution, chemical irritation, pressure by the catheter, peritonitis, or air pressing on the diaphragm, causing referred shoulder pain. b.Have the patient turn from side to side. c. Elevate head of bed at intervals. d.Allow the patient to sit in chair for brief periods if condition permits (only with surgically implanted catheter; with trocar, patient is usually on bed rest). 21.Observe for the following: 21.Leakage around the catheter predisposes the a. Abdominal pain: note the time of patient to infection at the exit site and discomfort during exchange cycle peritonitis. Dialysis may need to be terminated and duration of symptoms. if leakage persists. 15  b.Dialysate leakage: change the dressings frequently, being careful not to dislodge the catheter; use sterile plastic drapes to prevent contamination. c. Place the patient in a more upright position and use smaller fluid volumes to try to relieve pain and leakage. 22.Keep accurate records. 22.For proof of effectiveness of therapy and for a. Exact time of beginning and end of continuity of care. each exchange: starting and finishing time of drainage b.Amount of solution infused and recovered c. Fluid balance d.Number of exchanges e. Medications added to dialyzing solution f. Predialysis and postdialysis weight, plus daily weight g. Level of responsiveness at beginning, throughout, and at end of treatment h.Assessment of vital signs and patient's condition COMPLICATIONS Nursing Action Rationale 1. Peritonitis 1. Peritonitis is the most common complication. a. Watch for nausea and vomiting, Antibiotics may be added to dialysate and also anorexia, abdominal pain, given systemically. tenderness, rigidity, and cloudy dialysate drainage. b.Send specimen of dialysate for white cell count and full set of cultures. 2. Bleeding 2. A small amount of bleeding around the catheter a. Hematocrit of the drainage fluid may is not significant if it does not persist. During be taken to determine the amount of the first few exchanges, blood-tinged fluid from bleeding. subcutaneous bleeding is not uncommon. Small amounts of heparin may be added to inflow solution to prevent the catheter from becoming clogged. Continuous Ambulatory Peritoneal Dialysis Continuous ambulatory peritoneal dialysis (CAPD) is a form of intracorporeal dialysis that uses the peritoneum for the semipermeable membrane. The peritoneal catheter is implanted through the abdominal wall. Fluid infuses into the peritoneal cavity and drains after a prescribed time. 16 Procedure  A permanent indwelling catheter is implanted into the peritoneum; the internal cuff of the catheter becomes embedded by fibrous ingrowth, which stabilizes it and minimizes leakage.  A connecting tube is attached to the external end of the peritoneal catheter, and the distal end of the tube is inserted into a sterile plastic bag of dialysate solution.  The dialysate bag is raised to shoulder level and infused by gravity into the peritoneal cavity (approximately 10 minutes for a 2-L volume).  The typical dwell time is 4 to 6 hours.  At the end of the dwell time, the dialysate fluid is drained from the peritoneal cavity by gravity. Drainage of 2 L plus ultrafiltration takes about 10 to 20 minutes if the catheter is functioning optimally.  After the dialysate is drained, a fresh bag of dialysate solution is infused using aseptic technique, and the procedure is repeated.  The patient performs four to five exchanges daily, 7 days per week, with an overnight dwell time allowing uninterrupted sleep; most patients become unaware of fluid in the peritoneal cavity. Advantages over Haemodialysis  Physical and psychological freedom and independence  More liberal diet and fluid intake  Relatively simple and easy to use  Satisfactory biochemical control of uremia Complications  Infectious peritonitis, exit-site and tunnel infections.  Noninfectious catheter malfunction, obstruction, dialy-sate leak.  Peritoneal–pleural communication, hernia formation.  GI bloating, distention, nausea.  Hypervolemia, hypovolemia.  Bleeding at catheter site.  Bloody effluent secondary to internal bleeding. In female patients, this may occur during menstruation.  Obstruction may occur if omentum becomes wrapped around the catheter or the catheter becomes caught in a loop of bowel. Patient Education  The use of CAPD as a long-term treatment depends on prevention of recurring peritonitis. o Use strict aseptic technique when performing bag exchanges. o Perform bag exchanges in clean, closed-off area without pets and other activities. o Wash hands before touching bag. o Inspect bag, tubing for defects and leaks.  Do not omit bag changes: This will cause inadequate control of renal failure. 17   Some weight gain may accompany CAPD, the dialysate fluid contains a significant amount of dextrose, which adds calories to daily intake.  Report signs and symptoms of peritonitiscloudy peritoneal fluid, abdominal pain or tenderness, malaise, fever. Haemodialysis Haemodialysis is a process of cleansing the blood of accumulated waste products. It is used for patients with end-stage renal failure or for acutely ill patients who require short-term dialysis. Procedure  The patient's access is prepared and cannulated.  Heparin is administered (unless contraindicated).  Heparinized blood flows through a semipermeable dialyzer in one direction, and dialysis solution surrounds the membranes and flows in the opposite direction.  Dialysis solution consists of highly purified water to which sodium, potassium, calcium, magnesium, chloride, and dextrose have been added. Bicarbonate or acetate is also added to achieve the proper pH balance.  Through the process of diffusion, solute in the form of electrolytes, metabolic waste products, and acid–base components can be removed or added to the blood.  Excess water is removed from the blood (ultrafiltration).  The blood is then returned to the body through the patient's access. Requirements for Hemodialysis  Access to the patient's circulation  Dialysis machine and dialyzer with semipermeable membrane  Appropriate dialysate bath  Time—approximately 4 hours, three times weekly  Place—dialysis center or home (if feasible) Methods of Circulatory Access Arteriovenous fistula (AVF): this is the creation of a vascular communication by suturing a vein directly to an artery. o Usually, radial artery and cephalic vein are anastomosed in nondominant arm; vessels in the upper arm may also be used. o After the procedure, the superficial venous system of the arm dilates. o By means of two large-bore needles inserted into the dilated venous system, blood may be obtained and passed through the dialyzer. The arterial end is used for arterial flow and the distal end for reinfusion of dialyzed blood. o Healing of AVF requires several weeks; a central vein catheter is used in the interim.  Arteriovenous graft arteriovenous connection consisting of a tube graft made from autologous saphenous vein or from polytetrafluoroethylene. Ready to use in 2 to 3 weeks.  Central vein catheters is direct cannulation of veins (subclavian, internal jugular, or femoral); may be used as temporary or permanent dialysis access. Complications of Vascular Access 18   Infection  Catheter clotting  Central vein thrombosis or stricture  Stenosis or thrombosis  Ischemia of the hand (steal syndrome)  Aneurysm or pseudoaneurysm Monitoring During Haemodialysis  Involves constant monitoring of hemodynamic status, electrolyte, and acid-base balance as well as maintenance of sterility and a closed system.  Usually performed by a specially trained nurse who is familiar with the protocol and equipment being used. Lifestyle Management for Chronic Hemodialysis  Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake.  Ongoing health care monitoring includes careful adjustment of medications that are normally excreted by the kidney or are dialyzable.  Surveillance for complications. KIDNEY SURGERY Kidney surgery may include nephrectomy (removal of the kidney), kidney transplantation for end-stage renal disease (ESRD), procedures to remove stones or tumours, and procedures to insert drainage tubes (nephrostomy). Incisional approaches vary but may involve the flank, thoracic, and abdominal regions. Nephrectomy is most commonly performed for malignant tumors of the kidney but may also be indicated for trauma and kidneys that no longer function due to obstructive disorders and other renal disease. The absence of one kidney does not result in impaired renal function when the remaining kidney is normal. Many surgical procedures were previously performed as open procedures, but are now being done with laparoscopic keyhole surgeries. An endoscope is introduced, and the abdomen is inflated with carbon dioxide. Instruments are passed through other sites, or a sleeve may be used, which allows a hand to be introduced at the operative site. Advantages are decreased postoperative pain, decreased blood loss, and decreased length of stay (3 to 4 days for nephrectomy patients). Preoperative Management  The patient is prepared for surgery, and consent is witnessed.  Preoperative antibiotics and bowel cleansing regimen are prescribed.  Risk factors for thromboembolism are identified (smoking, oral contraceptive use, varicosities of lower extremities), and antiembolism stockings may be applied. Leg exercises are taught, and the patient is prepared for pneumatic/sequential compression stockings that will be used postoperatively.  Pulmonary status is assessed (presence of dyspnea, productive cough, other related cardiac symptoms), and deep-breathing exercises, effective coughing, and use of incentive spirometer are taught.  If embolization of the renal artery is being done preoperatively for patients with renal cell carcinoma, the following symptoms of postinfarction syndrome are observed for (may last up to 3 days): 19  o Flank pain o Fever o Leukocytosis o Hypertension Postoperative Management  Vital signs are monitored, and incisional area is assessed for evidence of bleeding or haemorrhage.  Pulmonary complications of atelectasis, pneumonia, and pneumothorax are observed for. Pulmonary toilet through deep breathing, percussion, and vibration is maintained. Chest tube drainage may be used (the proximity of the thoracic cavity to the operative area may result in the need for chest tube drainage postoperatively).  Patency of urinary drainage tubes is maintained (nephrostomy, suprapubic, or urethral catheter). Ureteral stents may be used.  Respiratory status and lower extremities are assessed for thromboembolic complications.  Bowel sounds, abdominal distention, and pain are monitored, which may indicate paralytic ileus and need for nasogastric decompression.  For kidney transplantation patients, immunosuppressant drugs (corticosteroids in combination with azathioprine [Imuran] or another agent) are ordered. Early signs of rejection include temperature greater than 100.4° F (38° C), decreased urine output, weight gain of 3 lb (1.5 kg) or more overnight, pain or tenderness over the graft site, hypertension, increased serum creatinine. Nursing Diagnoses  Acute Pain related to surgical incision  Impaired Urinary Elimination related to urinary drainage tubes or catheters  Risk for Infection related to incision, potential pulmonary complications, and possibly immunosuppression  Risk for Deficient or Excess Fluid Volume related to fluid replacement needs and transplanted/remaining kidney function Patient Education and Health Maintenance After Nephrectomy  Provide information about continued recovery from surgery; regular exercise, refraining from heavy lifting or strenuous activities, resumption of normal dietary intake.  Advise wearing a Medic-Alert bracelet, and inform all health care providers of solitary kidney status.  Encourage close follow-up and need to seek medical attention for any signs of urinary infection or urinary tract disease if there is only one kidney present to prevent damage to that kidney. After Kidney Transplantation  Explain and reinforce symptoms of rejection: fever, chills, sweating, lassitude, hypertension, weight gain, peripheral oedema, and decrease in urine output. Acute 20  rejection is common and usually reversible; commonly occurs in first 2 months after transplantation.  Prepare patient for possible need for maintenance dialysis when rejection occurs. If the transplanted kidney is rejected, it may be removed in the initial postoperative period. For chronic rejection, the kidney is not typically removed.  Explain continued protection of vascular access graft, which may still be enlarged, tender to palpation, associated with edema of overlying tissues.  Encourage compliance with laboratory tests (blood urea nitrogen [BUN], creatinine, serum chemistry, hematology, bacteriology, cyclosporine, or tacrolimus levels) to monitor recipient's immune status and detect early signs of rejection.  Instruct patient and family about prescribed immunosuppressants and complications of therapy; infection or incomplete control of rejection. o Review immunosuppressive medications in detail, including color identification of pills, dose schedules, adverse effects, and the necessity for taking the medication. o Review other medications, such as histamine-2 (H2) blockers, to prevent stress ulcers and prophylaxis for Candida and community-acquired infections.  Review in detail postoperative self-care regimen (may be inpatient or outpatient), including adequate fluid intake, daily weight, measurement of urine, stool test for occult blood, prevention of infection, exercise.  Instruct to report immediately: o Decrease in urinary output o Weight gain, edema o Malaise, fever o Graft swelling and tenderness (visible and palpable below the skin) o Changes in blood pressure readings o Respiratory distress o Anxiety, depression, change in appetite or sleep  Advise avoidance of contact sports for life to prevent trauma to the transplanted kidney.  Stress that follow-up care after transplantation is a lifelong necessity. URINARY DIVERSION Urinary diversion refers to diverting the urinary stream from the bladder so that it exits by way of a new avenue. A number of operative procedures may be performed to achieve this Methods of urinary diversion include:  Ileal conduit (or Bricker's loop) most common; transplants the ureters into an isolated section of the terminal ileum, bringing one end through the abdominal wall to create a stoma. Urine flows from the kidney into the ureters, then through the ileal conduit, and exits through urinary stoma. The ureters may also be transplanted into a segment of the transverse colon (colon conduit).  Nephrostomy: insertion of a catheter into the renal pelvis by way of an incision into the flank or by percutaneous catheter placement into the kidney. They are rarely placed for long periods of time; they are a short-term method of diverting urine away from an obstruction or lesion below the level of the renal pelvis.  Continent urinary diversion procedures: create a urinary reservoir from an intestinal segment that is either brought to the skin using a valve mechanism that permits catheterization, or is anastomosed directly to the proximal urethra. 21 PROSTATIC SURGERY Prostatic surgery may be done for BPH or prostate cancer. Surgical approach depends on size of the gland, severity of obstruction, age, underlying health, and prostatic disease. Surgical Procedures  Transurethral resection of the prostate (TUR or TURP): most common and done without an incision by means of endoscopic instrument  Open prostatectomy o Suprapubic incision into suprapubic area and through bladder wall; commonly done for BPH o Perineal incision between scrotum and rectal area; may be done for poor surgical risk patients but causes highest incidence of urinary incontinence and impotence o Retropubic incision at level of symphysis pubis; preserves nerves responsible for sexual function in 50% of patients Preoperative Management  Information about the procedure and the expected postoperative care, including catheter drainage, irrigation, and monitoring of hematuria is discussed.  Complications of surgery are discussed. o Incontinence or dribbling of urine may occur for up to 1 year after surgery; pelvic floor (Kegel) exercises help regain urinary control. o Retrograde ejaculation: seminal fluid released into bladder and eliminated in the urine rather than through the urethra during intercourse; impotence is usually not a complication of TUR but commonly a complication of open prostatectomy.  Bowel preparation is given, or the patient is instructed in home administration and fasting after midnight.  Optimal cardiac, respiratory, and circulatory status should be achieved to decrease risk of complications.  Prophylactic antibiotics are ordered. Postoperative Management  Urinary drainage is maintained and observed for signs of hemorrhage.  Wound care is provided to prevent infection.  Pain is controlled, and early ambulation is promoted.  Surveillance is maintained for complications. o Wound infection and dehiscence o Urinary obstruction or infection o Hemorrhage o Thrombophlebitis, pulmonary embolism o Urinary incontinence, sexual dysfunction Nursing Diagnoses  Impaired Urinary Elimination related to surgical procedure and urinary catheter  Risk for Infection related to surgical incision, immobility, and urinary catheter  Acute Pain related to surgical procedure 22   Anxiety related to urinary incontinence, difficulty voiding, and erectile dysfunction RENAL AND UROLOGIC DISORDERS ACUTE RENAL FAILURE Acute renal failure is a syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria (less than 500 mL urine/24 hours), hyperkalemia, and sodium retention. Causes  Prerenal causes: result from conditions that decrease renal blood flow (hypovolemia, shock, hemorrhage, burns, impaired cardiac output, diuretic therapy)  Postrenal causes: arise from obstruction or disruption to urine flow anywhere along the urinary tract  Intrarenal causes: result from injury to renal tissue and are usually associated with intrarenal ischemia, toxins, immunologic processes, systemic and vascular disorders Pathophysiology  Onset: begins when the kidney is injured and lasts from hours to days.  Oliguric-anuric phase (urine volume less than 400 to 500mL/24 hours). o Accompanied by rise in serum concentration of elements usually excreted by kidney (urea, creatinine, organic acids, and the intracellular cations—potassium and magnesium). o There can be a decrease in renal function with increasing nitrogen retention even when the patient is excreting more than 2 to 3 L of urine daily—called nonoliguric or high-output renal failure.  Diuretic phase: begins when the 24-hour urine volume exceeds 500 mL and ends when the BUN and serum creatinine levels stop rising.  Recovery phase. o Usually lasts several months to 1 year. o Probably some scar tissue remains, but the functional loss is not always clinically significant. Clinical Manifestations  Prerenal: decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia  Postrenal: obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis  Intrarenal: presentation based on cause; edema usually present  Changes in urine volume and serum concentrations of BUN, creatinine, potassium, and so forth, as described above Diagnostic Evaluation  Urinalysis: reveals proteinuria, hematuria, casts  Rising serum creatinine and BUN levels  Urine chemistry examinations to distinguish various forms of acute renal failure; decreased sodium 23   Renal ultrasonography or estimate of renal size and to exclude a treatable obstructive uropathy Management Preventive Measures  Identify patients with preexisting renal disease.  Initiate adequate hydration before, during, and after any procedure requiring NPO status.  Avoid exposure to nephrotoxins. Be aware that the majority of drugs or their metabolites are excreted by the kidneys.  Monitor chronic analgesic use: some drugs may cause interstitial nephritis and papillary necrosis.  Prevent and treat shock with blood and fluid replacement.  Prevent prolonged periods of hypotension.  Monitor urinary output and CVP hourly in critically ill patients to detect onset of renal failure at the earliest moment.  Schedule diagnostic studies requiring dehydration so there are rest days, especially in aged who may not have adequate renal reserve.  Pay special attention to draining wounds, burns, and so forth, which can lead to dehydration and sepsis and progressive renal damage.  Avoid infection; give meticulous care to patients with indwelling catheters and I.V. lines.  Take every precaution to make sure that the right person receives the right blood to avoid severe transfusion reactions, which can precipitate renal complications. Corrective and Supportive Measures  Correct reversible cause of acute renal failure (eg, improves renal perfusion, maximize cardiac output, surgical relief of obstruction).  Be alert for and correct underlying fluid excesses or deficits.  Correct and control biochemical imbalances: eg. Treatment of hyperkalemia.  Restore and maintain blood pressure.  Maintain nutrition.  Initiate haemodialysis, peritoneal dialysis, or continuous renal replacement therapy for patients with progressive renal failure and other life-threatening complications. Complications  Infection  Arrhythmias due to hyperkalemia  Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities  GI bleeding due to stress ulcers  Multiple organ systems failure Nursing Diagnoses  Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention 24   Risk for Infection related to alterations in the immune system and host defenses  Imbalanced Nutrition: Less Than Body Requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure  Risk for Injury related to GI bleeding  Disturbed Thought Processes related to the effects of uremic toxins on the central nervous system (CNS) CHRONIC RENAL FAILURE (END-STAGE RENAL DISEASE) Chronic renal failure (CRF, end-stage renal disease, ESRD) is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous wastes in the blood) and its complications unless dialysis or a kidney transplantation is performed. According to the National Kidney Foundation, approximately 20 million Americans have some type of chronic kidney disease. Most cases are asymptomatic until later stages. Causes  prolonged and severe Hypertension,  Diabetes mellitus  Glomerulopathies (from lupus or other disorders)  Interstitial nephritis  Hereditary renal disease, polycystic disease  Obstructive uropathy  Developmental or congenital disorder Pathophysiology  Rate of progression varies based on underlying cause and severity of that condition.  Stages: decreased renal reserve→renal insufficiency→renal failure→ESRD.  Retention of sodium and water causes edema, heart failure, hypertension, ascites.  Decreased glomerular filtration rate (GFR) causes stimulation of renin–angiotensin axis and increased aldosterone secretion, which raises blood pressure.  Metabolic acidosis results from the kidney's inability to excrete hydrogen ions, produce ammonia, and conserve bicarbonate.  Decreased GFR causes increase in serum phosphate, with reciprocal decrease in serum calcium and subsequent bone resorption of calcium.  Erythropoietin production by the kidney decreases, causing profound anemia.  Uremia affects the CNS, causing altered mental function, personality changes, seizures, and coma. Clinical Manifestations  GIT: anorexia, nausea, vomiting, hiccups, ulceration of GI tract, and hemorrhage  Cardiovascular: hyperkalemic ECG changes, hypertension, pericarditis, pericardial effusion, pericardial tamponade  Respiratory: pulmonary edema, pleural effusions, pleural rub  Neuromuscular: fatigue, sleep disorders, headache, lethargy, muscular irritability, peripheral neuropathy, seizures, coma  Metabolic and endocrine: glucose intolerance, hyperlipidemia, sex hormone disturbances causing decreased libido, impotence, amenorrhea 25   Fluid, electrolyte, acid: base disturbances usually salt and water retention but may be sodium loss with dehydration, acidosis, hyperkalemia, hypermagnesemia, hypocalcemia  Dermatologic: pallor, hyperpigmentation, pruritus, ecchymoses, uremic frost  Skeletal abnormalities: renal osteodystrophy resulting in osteomalacia  Hematologic: anemia, defect in quality of platelets, increased bleeding tendencies  Psychosocial functions: personality and behavior changes, alteration in cognitive processes Diagnostic Evaluation  Complete blood count (CBC): anemia (a characteristic sign)  Elevated serum creatinine, BUN, phosphorus  Decreased serum calcium, bicarbonate, and proteins, especially albumin  ABG levels: low blood pH, low carbon dioxide, low bicarbonate  24-hour urine for creatinine, protein, creatinine clearance Management Goal: conservation of renal function as long as possible.  Detection and treatment of reversible causes of renal failure (eg, bring diabetes under control; treat hypertension)  Dietary regulation: low-protein diet supplemented with essential amino acids or their keto analogues to minimize uremic toxicity and to prevent wasting and malnutrition  Treatment of associated conditions to improve renal dynamics o Anemia: recombinant human erythropoietin (Epo-gen), a synthetic hormone o Acidosis: replacement of bicarbonate stores by infusion or oral administration of sodium bicarbonate o Hyperkalemia: restriction of dietary potassium; administration of cation exchange resin o Phosphate retention: decrease dietary phosphorus (chicken, milk, legumes, carbonated beverages); administer phosphate-binding agents because they bind phosphorus in the intestinal tract  Maintenance dialysis or kidney transplantation when symptoms can no longer be controlled with conservative management Complications: Death Nursing Diagnoses  Excess Fluid Volume related to disease process  Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea, vomiting, and restricted diet  Impaired Skin Integrity related to uremic frost and changes in oil and sweat glands  Constipation related to fluid restriction and ingestion of phosphate-binding agents  Risk for Injury while ambulating related to potential fractures and muscle cramps due to calcium deficiency  Ineffective Therapeutic Regimen Management related to restrictions imposed by CRF and its treatment 26 ACUTE GLOMERULONEPHRITIS Acute glomerulonephritis refers to a group of kidney diseases in which there is an inflammatory reaction in the glomeruli. It is not an infection of the kidney, but rather the result of the immune mechanisms of the body. Pathophysiology and Aetiology  Occurs after an infection elsewhere in the body or may develop secondary to systemic disorders.  An antigen-antibody reaction produces immune complexes that lodge in the glomeruli, producing thickening of glomerular basement membrane; the renal vasculature, interstitium, and tubular epithelium may also be affected.  Immune complexes activate a variety of secondary mediators such as the complement pathways, neutrophils, macrophages, prostaglandins, and leukotrienes. These affect vascular tone and permeability, resulting in tissue injury.  Eventual scarring and loss of filtering surface may lead to renal failure. Clinical Manifestations  Mild disease is frequently discovered accidentally through a routine urinalysis.  History of infection: pharyngitis or impetigo from group A streptococcus, such viral infections as Epstein Barr and hepatitis B  Tea-coloured urine, oliguria  Puffiness of face, edema of extremities  Fatigue and anorexia, possible headache  Hypertension (mild, moderate, or severe)  Anemia from loss of RBCs into the urine  The clinical course of acute glomerulonephritis proceeds as follows from onset of symptoms to recovery; more than 90% of patients regain normal renal function within 60 days: o Diuresis usually starts 1 to 2 weeks after onset of symptoms. o Renal clearances and blood urea concentration return to normal. o Edema decreases, and hypertension lessens. o Microscopic proteinuria or hematuria may persist many months. Diagnostic Evaluation  Urinalysis for hematuria (microscopic or gross), proteinuria, cellular elements, and various casts.  24-hour urine for protein (increased) and creatinine clearance (reduced) outline the degree of renal function.  Elevated BUN and serum creatinine levels, low albumin level, increased antistreptolysin titer (from reaction to streptococcal organism), and decreased serum complement.  Needle biopsy of the kidney reveals obstruction of glomerular capillaries from proliferation of endothelial cells. Management  Management is symptomatic and includes antihypertensives, diuretics, drugs for management of hyperkalemia (due to renal insufficiency), H2 blockers (to prevent 27  stress ulcers), and phosphate-binding agents (to reduce phosphate and elevate calcium).  Antibiotic therapy is initiated to eliminate infection (if still present).  Fluid intake is restricted.  Dietary protein is restricted moderately if there is oliguria and the BUN is elevated. It is restricted more drastically if acute renal failure develops.  Carbohydrates are increased liberally to provide energy and reduce catabolism of protein.  Potassium and sodium intake is restricted in presence of hyperkalemia, edema, or signs of heart failure. Complications  Hypertension, heart failure, endocarditis  Fluid and electrolyte imbalances in the acute phase, hyperkalemia, hyperphosphatemia, hypervolemia  Malnutrition  Hypertensive encephalopathy, seizures  ESRD Nursing Diagnoses  Ineffective (Renal) Tissue Perfusion related to damage to glomerular function  Excess Fluid Volume related to compromised renal function NEPHROTIC SYNDROME Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia), edema, and excess lipids in the blood (hyperlipidemia). These occur as a consequence of excessive leakage of plasma proteins into the urine because of increased permeability of the glomerular capillary membrane. Pathophysiology and Etiology  Seen in any condition that seriously damages the glomerular capillary membrane. o Chronic glomerulonephritis o Diabetes mellitus with intercapillary glomerulosclerosis o Amyloidosis of kidney o Systemic lupus erythematosus o Renal vein thrombosis o Secondary to malignancy (older adults)  Hypoalbuminemia results in decreased oncotic pressure, causing generalized edema as fluid moves out of the vascular space  Decreased circulating volume then activates the renin-angiotensin system causing retention of sodium and further edema.  Mechanism for increased lipids is unknown. Clinical Manifestations 28   Insidious onset of pitting dependent edema, periorbital edema, and ascites; weight gain  Fatigue, headache, malaise, irritability  Marked proteinuria leading to depletion of body proteins  Hyperlipidemia may lead to accelerated atherosclerosis Diagnostic Evaluation  Urinalysis: marked proteinuria, microscopic hematuria, urinary casts, appears foamy  24-hour urine for protein (increased) and creatinine clearance (decreased)  Protein electrophoresis and immunoelectrophoresis of the urine to categorize the proteinuria  Needle biopsy of kidney for histologic examination of renal tissue to confirm diagnosis  Serum chemistry: decreased total protein and albumin, normal or increased creatinine, increased triglycerides, and altered lipid profile Management  Treatment of causative glomerular disease  Diuretics (used cautiously) and angiotensin converting enzyme inhibitors to control proteinuria  Corticosteroids or immunosuppressant to decrease proteinuria  General management of edema o Sodium and fluid restriction; liberal potassium o Infusion of salt-poor albumin o Dietary protein supplements  Low-saturated-fat diet Complications  Hypovolemia  Thromboembolic complications; renal vein thrombosis, venous and arterial thrombosis in extremities, pulmonary embolism, coronary artery thrombosis, cerebral artery thrombosis  Altered drug metabolism due to decrease in plasma proteins  Progression to end-stage renal failure Nursing Diagnoses  Risk for Deficient Fluid Volume related to disease process  Risk for Infection related to treatment with immunosuppressants Patient Education and Health Maintenance  Teach patient signs and symptoms of nephrotic syndrome; also review causes, purpose of prescribed treatments, and importance of long-term therapy to prevent ESRD. 29   Instruct patient in adverse effects of prescribed medications and methods of preventing infection if taking immunosuppressants.  Carefully review with patient and family dietary and fluid restrictions; consult dietitian for assistance in meal planning.  Discuss the importance of maintaining exercise, decreasing cholesterol and fat intake, and changing other risk factors, such as smoking, obesity, and stress, to reduce risk of severe thromboembolic complications.  In patients with severe disease, prepare for dialysis and possible transplantation. URINARY DISORDERS LOWER URINARY TRACT INFECTIONS A UTI is caused by the presence of pathogenic microorganisms in the urinary tract with or without signs and symptoms. Lower UTIs may predominate at the bladder (cystitis) or urethra (urethritis). Bacteriuria refers to the presence of bacteria in the urine (105 bacteria/mL of urine or greater generally indicates infection). In asymptomatic bacteriuria, organisms are found in urine, but the patient has no symptoms. Recurrent UTIs may indicate the following: Relapse recurrent infection with an organism that has been isolated during a prior infection Reinfection: recurrent infection with an organism distinct from previous infecting organism Pathophysiology and Etiology  Ascending infection after entry by way of the urinary meatus o Women are more susceptible to developing acute cystitis because of shorter length of urethra, anatomical proximity to vagina, periurethral glands, and rectum (fecal contamination), and the mechanical effect of coitus. o Women with recurrent UTIs typically have gram-negative organisms at the vaginal introitus; there may be some defect of the mucosa of the urethra, vagina, or external genitalia of these patients that allows enteric organisms to invade the bladder. o Poor voiding habits may result in incomplete bladder emptying, increasing the risk of recurrent infection. o Acute infection in women most commonly arises from organisms of the patient's own intestinal flora (Escherichia coli).  Although E. coli causes 86% of UTIs, other pathogens, such as Klebsiella species, Proteus species, and Staphylococcus saprophyticus, may also cause these infections.  In men, obstructive abnormalities (strictures, prostatic hyperplasia) are the most frequent cause.  UTI is a considerable source of nosocomial infection and sepsis in older adults.  Upper urinary tract disease may occasionally cause recurrent bladder infection. Clinical Manifestations  Dysuria, frequency, urgency, nocturia 30   Suprapubic pain and discomfort  Microscopic or gross hematuria Diagnostic Evaluation  Urine dipstick may react positively for blood, white blood cells (WBCs), and nitrates indicating infection.  Urine microscopy shows RBCs and many WBCs per field without epithelial cells.  Urine culture is used to detect presence of bacteria and for antimicrobial sensitivity testing.  Patients with indwelling catheters may have asymptomatic bacterial colonization of the urine without UTI. In these patients, UTI is diagnosed and treated only when symptoms are present. Management  Antibiotic therapy according to sensitivity results o A wide variety of antimicrobial drugs are available. o Urinary infections usually respond to drugs that are excreted in urine in high concentrations; a potentially effective drug should rapidly sterilize the urine and thus relieve the patient's symptoms.  For uncomplicated infection o Women with uncomplicated cystitis may be treated with a 3-day course of a fluoroquinolone such as ciprofloxacin, a 7-day course of nitrofurantoin (Macrodantin), or a 3-day course of co-trimoxazole. Seven to 10 days of therapy are recommended for women over age 65. o Men are treated with 7 to 10 days of antibiotic therapy. o Follow-up culture to prove treatment effectiveness may be indicated. o Adverse effects include nausea, diarrhea, drug-related rash, and vaginal candidiasis.  Pregnant women are usually treated for 7 to 10 days.  Women with recurrent infections may be treated longer, undergo diagnostic testing to rule out a structural abnormality, or be maintained on a daily dose of antibiotic as prophylaxis.  For complicated infection, use strong antibiotics like Augmentin, cifuroxine,  For severe discomfort with voiding, phenazopyridine (Pyridium) may be ordered three times per day for 2 days. Complications  Pyelonephritis  Hematogenous spread resulting in sepsis Nursing Diagnoses  Acute Pain related to inflammation of the bladder mucosa  Deficient Knowledge related to prevention of recurrent UTI Patient Education and Health Maintenance 31   Advise women with simple, uncomplicated cystitis that they do not require follow-up as long as symptoms are completely resolved with antibiotic therapy. Men usually need follow-up cultures and possibly additional testing if more than one episode of infection.  Instruct patient to void frequently (every 2 to 3 hours) and to empty bladder completely because this enhances bacterial clearance, reduces urine stasis, and prevents reinfection. Infrequent voiding distends the bladder wall, leading to hypoxia of bladder mucosa, which is then more susceptible to bacterial invasion.  Instruct patients who have had UTIs during pregnancy to have follow-up studies.  Female patients with uncomplicated but recurrent cystitis may self-administer a 2- or 3-day course of antibiotics when symptoms begin if so prescribed.  Recommend self-administration of acidophilus during course of antibiotic therapy to prevent vaginal candidiasis.  Cranberry (juice or capsules) may help to prevent cystitis by altering the chemical composition of the urine. Acidophilus and cranberry capsules are available in health food and vitamin stores. INTERSTITIAL CYSTITIS Interstitial cystitis is a syndrome of chronic, cystitis-like symptoms in the absence of bacterial infection. Pathophysiology and Etiology  The etiology of interstitial cystitis in unknown. Theories include an inflammatory or autoimmune process that alters the normal configuration of cells in the bladder epithelium, although infectious, neurological, psychological, and vascular origins are also considered possible. o One plausible theory is a neurogenic origin, in which an initial peripheral inflammatory response later activates the sacral nerves to continue to respond without evidence of continued inflammation. o Mast cell involvement in the inflammatory response also seems a plausible etiology, with many patients having a concomitant history of allergies.  The bladder is normally lined with a gel-like substance composed of glycosaminoglycans (heparin, hyaluronic acid, and chondroitin) that acts as an impermeable barrier to irritating solutes such as potassium.  Disruption to the bladder epithelium leads to irritant seepage, which produces the symptoms.  The bladder wall is chronically inflamed with no evidence of bacterial infection.  Occurs far more frequently in women than in men (9:1). Clinical Manifestations  Intermittent flares of urgency and frequency that resolve spontaneously may be the early presentation.  Urgency may be extreme and frequency (as many as 16 times per day) and nocturia increase with duration of symptoms.  Continuous bladder pain, may increase during voiding, may be diffuse perineal, vaginal, suprapubic pain, or lower back.  Symptoms are exacerbated by sexual intercourse and at the time of menstruation.  Symptoms may be present for 5 to 7 years before diagnosis is made. 32 Diagnostic Evaluation  Tender bladder base during pelvic examination, assessed by palpation of the anterior vaginal wall.  Cystoscopy under anesthesia with bladder biopsies and bladder distention; presence of bleeding or ulcerations on bladder distention is characteristic of some cases of interstitial cystitis.  Urodynamic tests commonly reveal a small bladder capacity with early sensation of urgency and, in some cases, poor detrusor function with incomplete bladder emptying.  In potassium sensitivity testing, symptoms are produced when potassium placed in bladder.  Diagnosis is usually made by ruling out other potential causes of symptoms, including radiation or chemical cystitis, gynecologic or urologic malignancies, STD, and urolithiasis. Management  Treatment is individualized and focused on symptom control.  Dietary modification to identify foods that act as triggers can be accomplished through an elimination diet. Possible triggers are citrus fruits, tomatoes, caffeinated beverages, carbonated beverages, chocolate, and spicy foods.  Bladder retraining (increasing intervals between voiding) is commonly necessary to increase bladder capacity that has been diminished by frequent voiding; pelvic floor strengthening with Kegel exercises can help with urgency and frequency.  Oral administration of pentosan polysulfate (Elmiron) relieves symptoms in some patients, with maximal effect seen after 3 to 6 months; many continue this therapy for years.  Antihistamines may be beneficial for patients who have allergies.  Tricyclic antidepressants may be helpful for their analgesic, anticholinergic, and antihistaminic effects. Gabapentin (Neurontin) is also used for the chronic pain.  Bladder distention during cystoscopy under general anaesthesia relieves symptoms in 20% to 25% of patients, especially those with small bladder capacity. Relapse commonly occurs 3 months post-treatment, however, and the effectiveness of this treatment diminishes with repeated use.  Intravesical therapy with various substances, including silver nitrate and dimethyl sulfoxide, may be used as a last resort.  Transcutaneous electrical nerve stimulation has demonstrated some relief for the pain syndrome associated with interstitial cystitis.  Surgical intervention may be performed in extreme cases, although its success is limited. Procedures include implantation of a sacral neuromodulation device, removal of bladder epithelial lesions, and cystectomy with urinary diversion. Complications  Psychosocial problems related to pain, urgency, and frequency  Secondary bacteriuria Nursing Diagnoses  Chronic Pain related to disease process 33   Impaired Urinary Elimination related to frequency, urgency, dysuria, and nocturia  Ineffective Coping related to interruption of lifestyle and chronic, unrelenting symptoms ACUTE BACTERIAL PYELONEPHRITIS Bacterial pyelonephritis is an acute infection and inflammatory disease of the kidney and renal pelvis involving one or both kidneys. Pathophysiology and Etiology  Enteric bacteria such as E. coli, is most common pathogen; other gram-negative pathogens include Proteus species, Klebsiella, and Pseudomonas. Gram-positive bacteria are less common, but include Enterococcus and Staphylococcus aureus.  Bacterial infection usually ascends from the lower urinary tract; however, hematogenous migration is possible (particularly with S. aureus).  Pyelonephritis can result from urinary obstruction such as vesicoureteral reflux (incompetence of ureterovesical valve, which allows urine to regurgitate into ureters, usually at time of voiding), other renal disease, trauma, or pregnancy.  Low-grade inflammation with interstitial infiltrations of inflammatory cells may lead to tubular destruction and abscess formation.  Chronic pyelonephritis may result in scarred, atrophic, and nonfunctioning kidneys. Clinical Manifestations  Fever, chills  Flank pain (with or without radiation to groin)  Nausea, vomiting, anorexia  Costovertebral angle tenderness  Urgency, frequency, and dysuria may be present Diagnostic Evaluation  Urinalysis (dipstick or microscopic) to identify leukocytes, bacteria, and RBCs and WBCs in urine; white cell casts may also be seen.  Urine culture to identify causative bacteria.  CBC shows elevated WBC count consisting of neutrophils and bands.  Intravenous urography (IVU) or renal ultrasound to evaluate for urinary tract obstruction; other radiologic or urinary tests as necessary. Management  For severe infections (dehydrated, cannot tolerate oral intake) or complicating factors (suspected obstruction, pregnancy, advanced age), inpatient antibiotic therapy is recommended. o Usually immediate treatment is started with a penicillin or aminoglycoside I.V. to cover the prevalent gram-negative pathogens; subsequently adjusted according to culture results. o An oral antibiotic may be started 24 hours after fever has resolved and oral therapy continued for 3 weeks. 34   Oral therapy antibiotic therapy is acceptable for outpatient treatment. o Co-trimoxazole (Septrin) or a fluoroquinolone is used; 10 to 14 days is the usual length of treatment.  Repeat urine cultures should be performed after the completion of therapy.  Supportive therapy is given for fever and pain control and hydration. Complications  Bacteremia with sepsis  Papillary necrosis leading to renal failure  Renal abscess requiring treatment by percutaneous drainage or prolonged antibiotic therapy  Perinephric abscess  Paralytic ileus Nursing Diagnoses  Hyperthermia due to infection  Acute Pain related to renal swelling and edema NEPHROLITHIASIS AND UROLITHIASIS Nephrolithiasis refers to renal stone disease; urolithiasis refers to the presence of stones in the urinary system. Stones, or calculi, are formed in the urinary tract from the kidney to bladder by the crystallization of substances excreted in the urine. Aetiology  Most stones (75%) are composed mainly of calcium oxalate crystals; the rest are composed of calcium phosphate salts, uric acid, struvite (magnesium, ammonium, and phosphate), or the amino acid cystine.  Causes and predisposing factors: o Hypercalcemia and hypercalciuria caused by hyperparathyroidism, renal tubular acidosis, multiple my-eloma, and excessive intake of vitamin D, milk, and alkali o Chronic dehydration, poor fluid intake, and immobility o Diet high in purines and abnormal purine metabolism (hyperuricemia and gout) o Genetic predisposition for urolithiasis or genetic disorders (cystinuria) o Chronic infection with urea-splitting bacteria (Proteus vulgaris) o Chronic obstruction with stasis of urine, foreign bodies within the urinary tract o Excessive oxalate absorption in inflammatory bowel disease and bowel resection or ileostomy o Living in mountainous, desert, or tropical areas Pathophysiology  Stones may be found anywhere in the urinary system and vary in size from mere granular deposits (called sand or gravel) to bladder stones the size of an orange. 35   Three out of four patients with stones are men; in both sexes, the peak age of onset is between ages 20 and 40.  Most stones migrate downward (causing severe colicky pain) and are discovered in the lower ureter. Spontaneous stone passage can be anticipated in 80% of patients with urolithiasis.  Some stones may lodge in the renal pelvis, ureters, or bladder neck causing obstruction, edema, secondary infection and, in some cases, nephron damage.  People who have had two stones tend to have recurrences. Clinical Manifestations  Pain pattern depends on site of obstruction o Renal stones produce an increase in hydrostatic pressure and distension of the renal pelvis and proximal ureter causing renal colic. Pain relief is immediate after stone passage. o Large ureteral stones produce symptoms or obstruction as they pass down the ureter (ureteral colic). o Bladder stones produce symptoms similar to cystitis.  Obstruction: stones blocking the flow of urine will produce symptoms of UTI; chills and fever.  GI symptoms include nausea, vomiting, diarrhoea, abdominal discomfort due to reno- intestinal reflexes and shared nerve supply (celiac ganglion) between the ureters and intestine. Diagnostic Evaluation  Kidney, ureters, and bladder radiography may show stone.  IVU to determine site and evaluate degree of obstruction; ultrasound may be as sensitive if technique is good.  Spiral CT scan: special CT technique to assess for stone in ureter. o Requires no preparation and is noninvasive. o Takes only 10 minutes; can replac