Urinary System Disorders - Nursing Notes PDF

Disease: **Urinary Incontinence** **Pathophysiology/Etiology:** an involuntary loss of urine severe enough to cause social or hygienic problems. It is not a normal consequence of aging or childbirth and often is a stigmatizing and an underreported health problem Types: - **Stress:** is the most...

Disease: **Urinary Incontinence** **Pathophysiology/Etiology:** an involuntary loss of urine severe enough to cause social or hygienic problems. It is not a normal consequence of aging or childbirth and often is a stigmatizing and an underreported health problem Types: - **Stress:** is the most common type urinary incontinence. Its main feature is the inability to retain urine when laughing, coughing, sneezing, jogging, or lifting. - **Urge:** is the loss of urine for no apparent reason after suddenly feeling the need or urge to urinate. Normally when the bladder is full, contraction of the smooth muscle fibers of the bladder detrusor muscle signals the brain that it is time to urinate. - **Overflow:** occurs when the detrusor muscle fails to contract and the bladder becomes overdistended. This type of incontinence (reflex incontinence or underactive bladder) occurs when the bladder has reached its maximum capacity and some urine must leak out to prevent bladder rupture - **Functional:** occurs as a result of factors other than the abnormal function of the bladder and urethra. A common factor is the loss of cognitive function in patients affected by dementia**.** **Signs/Symptoms:** - Distended abdomen - Inspect females for prolapse - Health care provider will perform comprehensive examination include - DRE for males - Leakage **Risk Factors:** Drugs - Central nervous system depressants, such as opioid analgesics, decrease the patient's level of consciousness and the urge to void and contribute to constipation. - Diuretics cause frequent voiding, often of large amounts of urine. - Multiple drugs can contribute to changes in mental status or mobility, and they can irritate the bladder. - Anticholinergic drugs or drugs with anticholinergic side effects are especially challenging because they affect both cognition and the ability to void. Monitor patient responses to these drugs early in treatment. Disease - Stroke, Parkinson disease, dementia, and other neurologic disorders decrease mobility, sensation, or cognition. - Arthritis decreases mobility and causes pain. Depression - Depression decreases the energy necessary to maintain continence. - Decreased self-esteem and feelings of self-worth decrease the importance to the patient of maintaining continence. Inadequate Resources - Patients who need assistive devices (e.g., eyeglasses, cane, walker) may be afraid to ambulate without them or without personal assistance. - Products that help patients manage incontinence of urine elimination are often costly. - No one may be available to assist the patient to the bathroom or help with incontinence products. **Labs/Diagnostic**: - Urinalysis - Imaging assessment - Bladder scan - CT of kidneys and ureters - VCUG - Urodynamic testing - EMG of pelvic muscles **Potential Complications:** - impaired comfort - activity disruption - shame or embarrassment - loss of tissue integrity **Treatment/Medications**: - Nutrition therapy:Nutrition therapy with weight reduction is helpful for patients who are obese because stress incontinence is made worse by increased abdominal pressure from obesity - Drug therapy: i. Hormones-Thought to enhance nerve conduction to the urinary tract, improve blood flow, and reduce tissue deterioration of the urinary tract ii. Anticholinergics- Suppress involuntary bladder contraction and increase bladder capacity(oxybutynin) - Devices**- pessary** (plastic device, often ring shaped, that helps hold internal organs in place) inserted into the vagina may help with a prolapsed uterus or bladder when this condition is contributing to urinary incontinence. - Electrical stimulation - Magnetic resonance therapy - Pelvic muscle therapy (kegel exercises) - Vaginal cone therapy - Behavioral interventions-habit training - Surgical management- A sling procedure creates a sling around the bladder neck and urethra using strips of body tissue or synthetic mesh. **NSG Interventions:** pt teaching **Pt Education:** - Maintain a normal body weight to reduce the pressure on your bladder. - Do not try to control your incontinence by limiting your fluid intake. Adequate fluid intake is necessary for kidney function and health maintenance. Disease: **Cystitis** **Pathophysiology/Etiology**: Inflammatory condition of the bladder. Commonly, it refers to inflammation from an infection of the bladder, however, cystitis can be caused by inflammation without **Signs/Symptoms:** - Frequency/urgency - dysuria - Fever - Chills - nausea **Risk Factors:** - infection - drugs, chemicals, or local radiation therapy cause bladder inflammation without an infecting organism. - Irritants, such as feminine hygiene spray, spermicidal jellies, - long-term use of a catheter can cause cystitis without infection. - Cystitis may sometimes occur as a complication of other disorders, such as gynecologic cancers, pelvic inflammatory disorders, endometriosis, Crohn's disease, diverticulitis, lupus, or tuberculosis. **Labs/Diagnostic**: - UA - Culture & Sensitivity - Pelvic ultrasound - CT - Cystoscopy - WBCs - Assess for distended bladder **Potential Complications:** Could be a UTI which left untreated can cause urosepsis **Treatment/Medications**: Increase fluid intake, drug therapy if infectious, surgical if recurrent. **NSG Interventions:** Pt teaching, sterile technique to prevent CAUTi **Pt Education:** Teach pt when using catheters at home, they are single use only, with clean technique. Sterile technique is for hospital. Disease: **Urethritis** **Pathophysiology/Etiology**: is an inflammation of the urethra and can result from infectious and noninfectious conditions. Highest incidence is adults aged 20-24 - STI is the most common cause **Signs/Symptoms:** mucopurulent or purulent discharge, dysuria, discomfort **Risk Factors:** - Irritants, such as feminine hygiene spray, spermicidal jellies, - long-term use of a catheter - postmenopausal women- lower estrogen can cause this **Labs/Diagnostic**: - Test for STIs - All patients with urethritis should be tested for N. gonorrhoeae and C. trachoma with an endourethral (in men) or endocervical (women) smear. - A pregnancy test is performed for women who have had unprotected intercourse. In women, - a pelvic examination may reveal tissue changes from low estrogen levels in the vagina. - Urethroscopy may show low estrogen changes with inflammation of urethral tissues. - UA- may show pyuria ( WBC in URINE) **Potential Complications:** If STIs are left untreated, can cause infertility, secondary infections, and even death. **Treatment/Medications**: - Usually resolves spontaneously (unless STI is detected; then antibiotics are prescribed) - Postmenopausal women often have improvement in urethral symptoms with the use of estrogen vaginal cream. **NSG Interventions:** pt teaching **Pt Education:** depending on what caused the irritation Disease: **Urolithiasis** **Pathophysiology/Etiology**: the presence of calculi (stones) in the urinary tract. Most common associated condition is dehydration **Signs/Symptoms:** Stones often do not cause symptoms until they pass into the lower urinary tract, where they can cause excruciating pain **Risk Factors:** - Metabolic risk factors (e.g., dehydration) - Family history, obesity, diabetes, gout increase risk - Diet (e.g., increased sodium) - Past treatment (if a history of stone formation) **Labs/Diagnostic**: - Urinalysis - urine specific gravity and osmolarity - Urine pH can help in the determination of stone type. - High urine acidity (low urine pH) is associated with uric acid and cystine stones; high urine alkalinity (high urine pH) is associated with calcium phosphate and struvite stones. - A 24-hour urine analysis can determine whether supersaturation of common stone particles is present. Hematuria during renal colic is common, and blood may make the urine appear smoky or rusty. - RBCs are usually caused by stone-induced trauma to the lining of the ureter, bladder, or urethra. - WBCs and bacteria may be present as a result of urinary stasis. Increased turbidity (cloudiness) and odor indicate that infection may also be present. Microscopic examination of the urine may identify possible stone-forming crystals. - The serum WBC count is elevated with infection. Increases in the serum levels of calcium, phosphate, or uric acid levels indicate that excess minerals that may contribute to stone formation are present. - \*\*\*The current standard for confirming urinary stones is an unenhanced helical CT scan of the abdomen and pelvis. Most stones are radiopaque; and the size, location, and surrounding anatomic structures are easily seen. In settings where a CT is not available, a routine abdominal x-ray (KUB) is useful **Potential Complications:** - Recognize that urinary tract obstruction is an emergency and must be treated to preserve kidney function - Nephrolithiasis is the formation of stones in the kidney; - Ureterolithiasis formation of stones in the ureter. - Urosepsis if untreated **Treatment/Medications**: - Pain relief - Antibiotics - Strain urine - Lithotripsy - Ureteroscopy - Measures to prevent urinary obstruction by stones include a high intake of fluids (3 L/day or more) and accurate measures of intake and output. Fluid intake sufficient to provide diluted urine helps prevent dehydration, promotes urine flow, and decreases the chance of crystals forming a stone. **NSG Interventions:** Nursing interventions focus on pain relief and preventing infection and urinary obstruction. Most patients expel the stone without invasive procedures. **Pt Education:** teach about prevention: stay hydrated! Disease: **Urothelial Cancer** **Pathophysiology/Etiology**: - Malignant tumors of urothelium, lining of transitional cells in kidney, renal pelvis, ureters, urinary bladder, and urethra - "Bladder cancer" **Signs/Symptoms:** - Ask about the patient's perception of his or her general health - Ask about active and passive exposure to cigarette smoke. - To detect exposure to harmful environmental agents, ask the patient to describe his or her occupation and hobbies in detail. Also ask the patient to describe any change in the color, frequency, or volume of urine elimination and any abdominal discomfort. - Observe the patient's overall appearance, especially skin color and nutrition status. Inspect, percuss, and palpate the abdomen for asymmetry, tenderness, and bladder distention. - Examine the urine for color and clarity. - **Blood in the urine is often the first indication of bladder cancer.** **It may be gross or microscopic and is usually painless and intermittent.** - Dysuria, frequency, and urgency occur when infection or obstruction is also present. **Risk Factors:** - Exposure to toxins increases risk - Greatest risk factor is tobacco use **Labs/Diagnostic**: - The only significant finding on routine urinalysis is gross or microscopic hematuria. Bladder-wash specimens and bladder biopsies are the most specific tests for cancer - Cystoscopy is usually performed to evaluate painless hematuria. - A biopsy of a visible bladder tumor can be performed during cystoscopy. Cystoureterography may be used to identify obstructions, especially where the ureter joins the bladder. - CT scans show tumor invasion of surrounding tissues. Ultrasonography shows masses but is less valuable for tumor staging. - MRI may help assess deep, invasive tumors. **Potential Complications:** metastasis **Treatment/Medications**: - Prophylactic immunotherapy with BCG - Multi-agent chemotherapy; radiation therapy - **Surgical-Depends on type and stage of cancer, and patient's general health** - **Complete bladder removal** (cystectomy) with additional removal of surrounding muscle and tissue offers the best chance of a cure for large, invasive bladder cancers. Four alternatives for urine elimination are used after cystectomy: ileal conduit; continent pouch; bladder reconstruction, also known as neobladder; and ureterosigmoidostomy. **NSG Interventions:** pt education. Depends on tx **Pt Education:** - Smoking cessation - Use PPE around dry, liquid, or gaseous chemicals - Shower or bathe, and change clothing, as soon as contact with chemicals is completed Disease: **Pyelonephritis** **Pathophysiology/Etiology**: **Acute pyelonephritis** is an active bacterial infection bacterial infection that starts in bladder moves upward to infect the kidneys. \[ECOLI most common\] **chronic pyelonephritis** results from repeated or continued upper urinary tract infections that occur almost exclusively in patients who have anatomic abnormalities of the urinary tract (structural deformities, urinary stasis, obstruction, reflux) **Signs/Symptoms:** ACUTE: - fever - Chills - Tachycardia - Tachypnea - Flank pain - CVA tenderness - abdominal discomfort - nausea and vomiting - fatigue - burning - frequency/ urgency/ nocturia - recent UTI CHRONIC: - hypertension - inability to conserve urine - decreased urine - tendency to develop hyperkalemia and acidosis - \*\* Older adults can develop confusion **Risk Factors:** - Bacterial: Most common in women who are young and sexually active - Bacterial: Catheter placement with disease that reduces immunity (e.g. Diabetes M.) - Chronic: conditions that lead to relapsing inflammatory damage of the kidney. (e.g.) congenital structural abnormality, neurogenic bladder dysfunction, and primary vesicoureteral reflux **Labs/Diagnostic**: - \*\*Urinalysis is positive for bacteria and WBC - urine culture - Blood cultures may be obtained to determine the source and spread of infectious organisms. - Other blood tests include the WBC count and differential of the complete blood count - C-reactive protein and erythrocyte sedimentation rate (ESR) - (BUN) and creatinine - (GFR) also is used to trend kidney function. **Potential Complications:** Urosepsis, kidney abscesses, fibrosis scar tissue **Treatment/Medications**: - acetaminophen for pain - antibiotics to treat infection - catheter replacement for patients requiring a catheter for more than 2 weeks - nutrition therapy -- ensure that diet has adequate calories for healing. Consult a - Registered Dietician. - Fluid intake should be 2liters/day to dilute urine - Surgical- correct structural problems (pyelolithotomy, nephrectomy) **NSG Interventions:** pt teaching depending on tx **Pt Education:** If no surgery is performed, the patient may need help with self-care, nutrition, and drug management at home. If surgery is performed, he or she may need help with incision care, self-care, and transportation for follow-up appointments. Disease: **ACUTE** **Glomerulonephritis** **Pathophysiology/Etiology**: Develops suddenly from an excess immunity response within the kidney tissues Causes: - Group A beta-hemolytic Streptococcus - Staphylococcal or gram-negative bacteremia or sepsis - Pneumococcal, Mycoplasma, or Klebsiella pneumonia - Syphilis - Dengue - Hantavirus - Varicella - Parvovirus - Hepatitis B and C - Cytomegalovirus - Parvovirus - Epstein-Barr virus - Human immunodeficiency virus **Signs/Symptoms:** - Fluid overload - Skin lesions - edema in face eyelids & hands - crackles in lungs - blood in urine - dysuria/ oliguria - mild/moderate hypertension, - fatigue - anorexia - nausea/ vomiting. **Risk Factors:** Secondary disease that reduces immunity **Labs/Diagnostic**: - Urinalysis - 24 hours - Urine - creatinine, BUN, - kidney biopsy **Potential Complications:** Acute Kidney Failure, Disrupted fluid and electrolytes **Treatment/Medications**: - Fix the cause (strep tx)\[e.g\] - Diet mod: fluid and sodium restriction, Protein reduction, increase carbs - Bedrest - Daily weight. I & O - Monitor BP - Antihypertensive drugs may be needed to control **NSG Interventions:** Managing infection as a cause of acute GN begins with appropriate antibiotic therapy. Penicillin, erythromycin, or azithromycin is prescribed for GN caused by streptococcal infection. Preventing complications is an important nursing intervention, especially when fluid and electrolyte balance is disrupted. For patients with fluid overload, hypertension, and edema, diuretics and sodium and water restrictions are prescribed. The usual fluid allowance is equal to the 24-hour urine output plus 500 to 600 mL. Patients with oliguria usually have increased serum levels of potassium and blood urea nitrogen (BUN). Potassium and protein intake may be restricted to prevent hyperkalemia and uremia as a result of the elevated BUN. hypertension **Pt Education:** - Stress personal hygiene and basic infection control principles (e.g., handwashing) to prevent spread of the organism. - Teach patients the importance of completing the entire course of the prescribed antibiotic. - Patients receiving immunosuppressants need to take precautions to avoid exposure to new infections. Disease: **CHRONIC** **Glomerulonephritis** **Pathophysiology/Etiology**: - Chronic GN, or chronic nephritic syndrome, develops over years to decades. - Although the exact cause is not known, changes in kidney tissue result from infection, hypertension, inflammation from immunity excess, or poor kidney blood flow. **Signs/Symptoms:** Mild proteinuria and hematuria, hypertension, fatigue, and occasional edema are often the only symptoms. Assessment: - check for circulatory - overload, uremic symptoms(slurred - speech, ataxia, tremors), urine output - decreases and shows protein, sodium - retention **Risk Factors:** infection, hypertension, inflammation from immunity excess, or poor kidney blood flow. **Labs/Diagnostic**: - Check GFR (low) - urinalysis - Electrolytes hyponatremia - Hyperkalemia - hyperphosphatemia - X-ray- small kidneys, biopsy **Potential Complications:** Leads to end stage kidney disease\ **Treatment/Medications**: Eventually elimination is so impaired that the patient requires dialysis or transplantation to prevent death. **NSG Interventions:** Focus on slowing the progression of the disease and preventing complications: diet changes, fluid intake, drug therapy **Pt Education:** diet changes, fluid intake, drug therapy Disease: **NEPHROTIC SYNDROME** **Pathophysiology/Etiology**: Immunologic kidney disorder in which glomerular permeability increases so larger molecules pass through the membrane into the urine and are then excreted Common causes is altered immunity with inflammation. Assess hydration status **Signs/Symptoms:** - increased protein elimination with severe proteinuria - low albumin in the blood - high serum lipid levels - fats in the urine - edema - hypertension **Risk Factors:** - Systemic Diseases (e.g. Lupus or Diabetes M.) - Genetic - Bacterial/Viral infections - NSAIDs **Labs/Diagnostic**: - UA- Excessive proteinuria - identified by kidney biopsy - CMP- check for hypoalbuminemia **Potential Complications:** reduced kidney function\ **Treatment/Medications**: - ACE inhibitors to decrease protein loss - cholesterol-lowering drugs - heparin to reduce vascular defects and improve kidney function - diet changes: lower sodium, fats. Moderate protein intake. - Diuretics **NSG Interventions:** pt teaching **Pt Education:** diet changes: lower sodium, fats. Moderate protein intake. Disease: **Nephrosclerosis** **Pathophysiology/Etiology**: A degenerative disorder resulting from changes in kidney blood vessels. Nephron blood vessels thicken, resulting in narrowed lumens and decreased kidney blood flow. The tissue is chronically hypoxic, with ischemia and fibrosis developing over time. **Signs/Symptoms:** Hypertension **Risk Factors:** all types of hypertension, atherosclerosis, and diabetes mellitus (DM). **Labs/Diagnostic**: - UA - CMP - Kidney biopsy **Potential Complications:** The changes caused by hypertension may be reversible or may progress to end-stage kidney disease (ESKD) within months or years. **Treatment/Medications**: - Antihypertensive - Education - Diuretics **NSG Interventions:** pt teaching **Pt Education:** treat hypertension, diet changes Disease: **Polycystic Kidney Disease** **Pathophysiology/Etiology**: a genetic disorder in which fluid-filled cysts develop in the nephrons. Relentless development and growth of cysts from loss of cellular regulation and abnormal cell division result in progressive kidney enlargement. **Signs/Symptoms:** **Abdominal or flank Pain is often the first symptom** - Nocturia - Frequent urinary tract infections - Increased abdominal girth - Constipation - Hematuria - Sodium wasting and inability to concentrate urine in early stage - Progression to kidney failure with anuria - hypertension - abdominal fullness - episodes of cyst bleeding - kidney stone formation - infections - systemic disease **Risk Factors:** PKD can be inherited as either an autosomal dominant trait or, less often, an autosomal recessive trait. Autosomal dominant PKD is the most common inherited kidney disease, occurring in 1 in 400 to 1000 live births **Labs/Diagnostic**: Ultrasound is the primary method for diagnosing PKD. - The size of the kidney is measured by ultrasound as well as cysts within the kidney. - MRI or CT may be used in order to confirm ultrasound findings or when a family member is being evaluated for potential kidney donation - Urinalysis may show proteinuria - Hematuria may be gross or microscopic. - Bacteria in the urine indicate infection, usually in the cysts. Obtain a urine sample for culture and sensitivity testing when there is evidence of infection. **Treatment/Medications:** Currently no treatments are effective in extending kidney function in PKD. Drug therapies to interrupt the pathways that promote malignant cyst formation such as molecular signaling for cell division or endothelial growth are being evaluated. Supportive interventions for PKD include management of hypertension and pain, reducing complications from infection and constipation, and slowing disease progression. **Potential Complications:** a decline in kidney function and impaired elimination **NSG Interventions:** - manage blood pressure- ACE In. - manage pain- Opioids & Acetaminophen - reduce complications of infection- Hand Hygiene - prevent constipation- high fiber/stool softners - slow progression of CKD **Pt Education:** - Measure and record your blood pressure daily and notify your primary health care provider about consistent changes in blood pressure. - Take your temperature if you suspect you have a fever. If a fever is present, notify your physician or nurse. - Weigh yourself every day at the same time of day and with the same amount of clothing; notify your primary health care provider or nurse if you have a sudden weight gain. - Limit your intake of salt to help control your blood pressure once hyperfiltration is no longer a symptom of your disease (once chronic kidney disease \[CKD\] is present). - Notify your primary health care provider or nurse if your urine smells foul or has a new occurrence of blood in it. - Notify your primary health care provider or nurse if you have a headache that does not go away or if you have visual disturbances because these are symptoms of a stroke or bleeding in the brain. - Monitor bowel movements to prevent constipation. Disease: **Hydronephrosis and Hydroureter** **Pathophysiology/Etiology**: Hydronephrosis- the kidney enlarges as urine collects in the renal pelvis and kidney tissue, causing obstruction Hydroureter- enlargement of the ureters causing obstruction Interventions- Urogloic or Radiologic **Signs/Symptoms:** - flank pain - chills - fever - malaise may present as a UTI **Risk Factors:** a blockage in your urinary tract, urinary retention or backflow of pee (VUR) **Labs/Diagnostic**: Urinalysis shows bacteria or WBC Creatinine and BUN are elevated with decreased GFR Electrolytes: Nitrogen waste products (urea, creatinine, and uric acid) and electrolytes (sodium, potassium, chloride, and phosphorus) are retained, and acid-base balance is impaired. **Treatment/Medications:** Urologic Interventions If obstruction is caused by a kidney stone (calculus), it can be located and removed using cystoscopic or retrograde urogram procedures. After stone removal, a plastic stent is usually left in the ureter for a few weeks to improve urine flow in the area irritated by the stone. The stent is later removed by another cystoscopic procedure. Radiologic Interventions When an abnormal narrowing of the urinary tract (stricture) causes hydronephrosis and cannot be corrected with urologic procedures, a nephrostomy is performed. Most nephrostomy drains provide only external drainage (diversion). Other styles of nephrostomy drains enter the kidney and extend to the bladder, draining urine out to a bag or past a ureteral obstruction and into the bladder. With these, there are both internal and external parts to the nephrostomy tubing. Externally, a fully external or an internal/external diversion drain appears the same. The urine output will fluctuate more if all urine goes to the bladder before external drainage. **Potential Complications:** Urinary retention and potential for infection are the primary problems. Failure to treat the cause of obstruction leads to infection and acute kidney injury (AKI) **NSG Interventions:** After nephrostomy, monitor the patient for indications of complications (i.e., decreased or absent drainage, cloudy or foul-smelling drainage, leakage of blood or urine from the nephrostomy site, back pain. ) If any indications are present, respond by notifying the surgeon immediately **Pt Education:** notify MD if signs of infection Disease: **Renovascular Disease** **Pathophysiology/Etiology**: Processes affecting the renal arteries may severely narrow the lumen and greatly reduce blood flow to the kidney tissues. Uncorrected renovascular disease, such as renal vein thrombosis or renal artery stenosis (RAS), atherosclerosis, or thrombosis, causes ischemia and atrophy of kidney tissue. **Signs/Symptoms:** - difficult to control blood pressure - elevated serum creatinine - decreased GFR - poorly controlled diabetes **Risk Factors:** - Atherosclerosis - Diabetes - Hypertension - Morbid obesity **Labs/Diagnostic**: Conventional Contrast Angiography=gold standard **Treatment/Medications** - Identifying type of condition - renal artery bypass - AS may be managed by drugs to control high blood pressure and by procedures to restore the blood supply to the kidney. Drugs may control high blood pressure but may not lead to long-term preservation of kidney function. In younger adults, a lifetime of treatment with many drugs for high blood pressure makes treatment difficult and outcomes uncertain. - Endovascular techniques are nonsurgical approaches to repair RAS. Stent placement with or without balloon angioplasty is an example of an endovascular intervention **Potential Complications:** severe impairment of urinary elimination, fluid and electrolyte balance, and acid-base balance **NSG Interventions:** pt teaching **Pt Education:** Renal artery bypass surgery is a major procedure and requires 2 or more months for recovery. Disease: **Renal Cell Carcinoma** **Pathophysiology/Etiology**: Renal cell carcinoma (RCC) or adenocarcinoma of the kidney is the most common type of kidney cancer and occurs as a result of impaired cellular regulation. Healthy kidney tissue is damaged and replaced by cancer cells, which impairs urine elimination for that kidney **Signs/Symptoms:** - flank pain - obvious blood in the urine (a late common sign) - a kidney mass can be palpated **Risk Factors:** The causes of nonhereditary RCC are unknown, but the risk is slightly higher for adults who use tobacco or are exposed to cadmium and other heavy metals, asbestos, benzene, and trichloroethylene. Men are slightly more likely to acquire RCC, as are persons with obesity, those with hypertension, and African Americans. **Labs/Diagnostic**: - CT or MRI - urinalysis shows RBC - hemoglobin and hematocrit decrease - increased ESR - Elevated BUN and creatinine **Treatment/Medications:** - microwave ablation - Surgical: nephrectomy **Potential Complications:** - metastasis and urinary tract obstruction. - at risk for CKD and cardiovascular complications - When the cancer surrounds a ureter, hydroureter and obstruction may result. **NSG Interventions:** Pre-op & Post- OP usual **Pt Education:** smoking cessation Disease: **Acute Kidney Injury** **Pathophysiology/Etiology**: a **rapid reduction** in kidney function resulting in a failure to maintain waste elimination, fluid and electrolyte balance, and acid-base balance. AKI occurs over a few hours or days. The most current definition of AKI is an increase in serum creatinine by 0.3 mg/dL or more within 48 hours; or an increase in serum creatinine to 1.5 times or more from baseline, which is known or presumed to have occurred in the previous 7 days; or a urine volume of less than 0.5 mL/kg/hr for 6 hours Causes: - Blood or fluid loss - Blood pressure medications - Heart attack - Infection - severe burns - severe - dehydration - Blood clots - Glomerulonephritis - Lupus - Cancer - kidney stones **Signs/Symptoms:** - Oliguria - Hypotension - Azotemia - hypoxia - tachycardia - decreased cognition - Watch for signs of fluid overload **Risk Factors:** - Nephrotoxic drugs - Blood or fluid loss - Blood pressure medications - Heart attack - Heart disease - Infection (e.g., sepsis, septic shock) - Liver failure - Use of aspirin, ibuprofen, naproxen, or other related drugs - Severe allergic reaction (anaphylaxis) - Severe burns - Severe dehydration - Renal artery stenosis - Bleeding or clotting in the kidney blood vessels (coagulopathy) - Atherosclerosis or cholesterol deposits that block blood flow in the kidneys **Labs/Diagnostic**: - Creatinine and BUN will elevate, - electrolytes may be abnormal, - Urine sodium levels will be elevated - Use ultrasound - CT, or xray **Treatment/Medication**: - Avoid hypotension and maintain fluid balance - Reduce exposure to nephrotoxic drugs - Monitor for edema - Monitor lab work - Monitor I/O - Renal replacement therapies - Nutrition: 0.6g/kg of protein (not on dialysis)potassium restricted 60-70 meq - Fluid is determined on fluid balance **Potential Complications:** - Metabolic acidosis - Hyperlipidemia - Hyperkalemia - Hyponatremia - Hypocalcemia - Hypophosphatemia - Peripheral and pulmonary edema - Heart failure - Pulmonary embolism - Pericarditis - Pericardial effusion - Hypertension - Myocardial infarction - Neuromuscular irritability or weakness - Asterixis - Seizures - Mental status changes - Pneumonia - Sepsis **NSG Interventions:** - Assess characteristics of urine - Check I/O - Monitor labs **Pt Education:** - Urge healthy adults to drink 2-3 liters of fluids daily - Be aware of nephrotoxic substances - Interventions if urine output less than 60ml/hr, less than 30ml/hr, call the MD Disease: Chronic Kidney Disease **Pathophysiology/Etiology**: Unlike acute kidney injury (AKI), chronic kidney disease (CKD**) is a progressive, irreversible** disorder lasting longer than 3 months. When kidney function and waste elimination are too poor to sustain life, CKD becomes end-stage kidney disease (ESKD). Terms used with CKD include azotemia (buildup of nitrogen-based wastes in the blood), uremia (azotemia with symptoms) and uremic syndrome. CAUSES: - Glomerulonephritis - Nephrosclerosis - polycystic kidney disease - pyelonephritis - diabetes - hypertension - Lupus - Gout **UREMIA SYMPTOMS:** - Metallic taste in the mouth - Anorexia - Nausea - Vomiting - Muscle cramps - Uremic frost on skin - Fatigue and lethargy - Hiccups - Edema - Dyspnea - Paresthesia **Signs/Symptoms:** - Confusion - Drowsiness - Tremor - Ataxia - Hypertension - heart failure - edema - tachypnea - kussmaul respirations - abnormal - bleeding - polyuria - proteinuria - oliguria - depression - hyperkalemia **Risk Factors:** More than 100 different disease processes can result in progressive loss of kidney function. Two main causes of CKD leading to dialysis or kidney transplantation are hypertension and diabetes mellitus. African American patients are much more likely to develop ESKD and have hypertensive ESKD. **Labs/Diagnostic**: - Elevated BUN and creatinine - Electrolytes - H&H - GFR - urinalysis **Treatment/Medications:** Management of the patient with CKD includes drug therapy, nutrition Dialysis and kidney transplant are life-sustaining treatments for end-stage kidney disease (ESKD). Kidney transplant is not considered a "cure. therapy, fluid restriction, and dialysis (when the patient reaches stage 5). - Loop Diuretics - Phosphate binders form an insoluble calcium-phosphate complex to inhibit GI absorption to prevent hyperphosphatemia and renal osteodystrophy from hypocalcemia - Multivitamins and vitamin B supplements - Oral iron salts - Vitamin D - Erythropoietin-Stimulating Agents (ESAs) - Parathyroid Hormone Modulator A white paper with black text AI-generated content may be incorrect. **Potential Complications:** Complications during **Hemodialysis** include hypotension, dialysis disequilibrium syndrome, cardiac events, and reactions to dialyzers. Technical or human error can lead to avoidable complications (e.g., hemolysis, air embolism, dialysate error, contamination, exsanguination) - Disequilibrium syndrome - Muscle cramps and back pain - Headache - Itching - Hemodynamic and cardiac adverse events (hypotension, cell lysis contributing to anemia, cardiac dysrhythmias) - Infection - Increased risk for subdural and intracranial hemorrhage from anticoagulation and changes in blood pressure during dialysis - Anemia - Access site complications Peritonitis is the major complication of Peritoneal Dialysis most commonly caused by connection site contamination. **Action Alert** Monitor the patient to recognize indications of peritonitis (e.g., cloudy dialysate outflow (effluent), fever, abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting). Cloudy or opaque effluent is the earliest indication of peritonitis. Examine all effluent for color and clarity to detect peritonitis early. When peritonitis is suspected, respond by sending a specimen of the dialysate outflow for culture and sensitivity study, Gram stain, and cell count to identify the infecting organism. - Protein loss - Peritonitis - Respiratory distress - Inflammatory bowel disease - Bowel perforation - Infection - Weight gain; discomfort from "carrying" 1-2 L in abdomen during dwell time; potential for back pain or development of hernia **NSG Interventions:** - Protein restriction (if not on dialysis) - sodium restriction - potassium restriction - phosphorus restriction - vitamin and mineral supplementation - A urinalysis is performed. In the early stages of CKD, urinalysis may show protein, glucose, red blood cells (RBCs) and white blood cells (WBCs), and decreased or fixed specific gravity. **Pt Education:** Teach patients with mild chronic kidney disease (CKD) that carefully managing fluid volume, blood pressure, electrolytes, and other kidney-damaging diseases by following prescribed drug and nutrition therapies can slow progression to end-stage kidney disease (ESKD). - Control diseases that can cause CKD - weight maintenance - smoking cessation - physical activity - treat infections **Hemodialysis:** - Most common with ESKD - Dialysis settings- home, hospital, center - Procedure-uses passive transfer of toxins by diffusion - Anticoagulation- blood clotting can occur in dialysis, so heparin is given through a pump - Vascular access-AV fistulas, arteriovenous grafts - Nursing care- know what drugs are dialyzable  Post-dialysis care-monitor for side effects **Peritoneal Dialysis**: Siliconized rubber catheter placed into abdominal cavity for infusion of dialysate Types of PD (selection depends on patient's ability and lifestyle): - **Continuous ambulatory**: is performed by the patient with the infusion of four 2-L exchanges of dialysate into the peritoneal cavity. Each time, the dialysate remains for 4 to 8 hours, and these exchanges occur 7 days a week - Multiple-bag continuous ambulatory: - **Automated:** may be used in the acute care setting, the ambulatory care dialysis center, or the patient's home. APD uses a cycling machine for dialysate inflow, dwell, and outflow according to preset times and volumes. - **Intermittent:** combines osmotic pressure gradients with true dialysis. The patient usually requires exchanges of 2 L of dialysate at 30- to 60-minute intervals, allowing 15 to 20 minutes of drain time. - Continuous-cycle **Kidney Transplant:** Candidate selection criteria: - Free of problems that might raise procedural risk - Certain conditions preclude kidney transplant Donors: - Available kidneys matched based on tissue similarity between donor and recipient - Organs from Living Related Donors have highest rates of kidney graft survival - Physical criteria must be met - Immunologic studies are needed because the major barrier to transplant success after a suitable donor kidney is available is the body's ability to reject "foreign" tissue. - This immunologic process can attack the transplanted kidney and destroy it. - For normal protective immunity to be overcome, tissue typing with human leukocyte antigen (HLA) studies and blood-typing are performed on all candidates. - A donated kidney must come from a donor who is the same blood- type as the recipient. Urologic management: - Assessment of hourly urine - Output for first 48 hours - An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury (AKI), thrombosis, or obstruction. - Examine the urine color. The urine is pink and bloody right after surgery and gradually returns to normal over several days to several weeks, depending on kidney function. - Obtain daily urine specimens for urinalysis, glucose measurement, the presence of acetone, specific gravity measurement, and culture (if needed) Complications - Rejection : Rejection is the most serious complication of transplantation and is the leading cause of graft loss. A reaction occurs between the tissues of the transplanted kidney and the antibodies and cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis. - The three types of rejection are hyperacute, acute, and chronic. Acute rejection is the most common type with kidney transplants. It is treated with increased immunosuppressive therapy and often can be reversed. Rejection is diagnosed by symptoms, a CT or renal scan, and kidney biopsy. A screenshot of a medical report AI-generated content may be incorrect. - Thrombosis: of the major renal blood vessels may occur during the first 2 to 3 days after the transplant. A sudden decrease in urine output may signal impaired perfusion resulting from thrombosis. Ultrasound of the kidney may show decreased or absent blood supply. Emergency surgery is required to prevent ischemic damage or graft loss. - Renal artery stenosis: may result in hypertension. Other signs include a bruit over the artery anastomosis site and decreased kidney function. A CT or renal scan can quantify the perfusion to the kidney. - Other complications: may involve the surgical wound or urinary tract. Wound problems, such as hematomas, abscesses, and lymphoceles (cysts containing lymph fluid), increase the risk for infection and exert pressure on the new kidney. Immunosuppressive drug: The success of kidney transplantation depends on changing the patient's immunity response so the new kidney is not rejected as a foreign organ. Immunosuppressive drugs protect the transplanted organ. These drugs include corticosteroids, inhibitors of T-cell proliferation and activity (azathioprine, mycophenolic acid, cyclosporine, and tacrolimus), mTOR inhibitors (to disrupt stimulatory T-cell signals), and monoclonal antibodies. Patients taking these drugs are at an increased risk for death from infection. Usually, the patient receives a period of high-dose (induction) therapy followed by lower-dose maintenance immunosuppressive therapy.