Objective 6 Renal Alterations 2024.pdf

Objective 6 Med-Surg Nursing I Renal Alterations 2024 Purpose of the Renal System Maintain fluid and electrolyte homeostasis Excrete urine Buffering system to control pH Critical to the production of: Synthesize vitamin D to active form (necessary for maintaining blood calcium...

Objective 6 Med-Surg Nursing I Renal Alterations 2024 Purpose of the Renal System Maintain fluid and electrolyte homeostasis Excrete urine Buffering system to control pH Critical to the production of: Synthesize vitamin D to active form (necessary for maintaining blood calcium balance) Hormone that stimulates red blood cells (erythropoietin) Hormone that regulate blood pressure (renin) Activate growth hormone Secrete prostaglandins FUN FACTS The kidneys filter 1.2 liters blood per minute, creating 180 liters of filtrate (not yet urine) per day Each kidney has ~ 800,000 - 1 million nephrons 99% of the filtrate (pre-urine fluid) is reabsorbed back into the venous system to go back to the vena cava, then the heart. Only 1000-2000 ml urine per day is urine under normal conditions, with 70 mEq of acid. Urine pH 4.5. The bladder holds 400-500 ml. When it stretches from overfilling it never regains it natural shape and elasticity affecting the ability to urinate effectively. The body senses the urge to void when ~ 200 ml in the bladder (ability to hold- 2-4 hours) Micturition (urination)~ 8 times per day  Common Terms – table 47-7 Anuria is the absence of urine. Diuresis is an increase in the volume of urine. Dysuria is painful urination. Enuresis is involuntary nocturnal urination. Frequency is when the patient voids more frequently than what is usual for the patient. Nephritis is inflammation of the kidney. Hematuria is blood in the urine. Hesitancy is difficulty initiating urination. Incontinence is the inability of control urination or defecation. Lithiasis means the presence or formation of stones. Nocturia is excessive urination at night. Oliguria is a decrease in the formation or passing of urine. Polyuria is the passing of an abnormally large amount of urine. Proteinuria is the presence of an abnormally large amount of protein in the urine. Pyuria is the presences of an abnormal amount of white blood cells in the urine Urinary retention is the inability of the patient to empty their bladder. Urgency is an intense desire to urinate immediately. Factors that promote proper renal and Urinary function Adequate flow of blood to and from the kidney- good blood pressure, sufficient volume (intake of fluids) Functioning filtering system: nephrons, afferent (to) and efferent (from) arterioles supply and flow Patent ducts from kidney (ureter) and from bladder Intact bladder (no holes, tears) Proper nerve innovation and info relay (hormones) Functioning pelvic floor muscles ( and sphincter function Proper pH Diagnostic Tests Independent Study Table 47-8 Urinalysis and urine culture Renal function tests: SG, osmolality, 24 hr urine, etc Ultrasonography CT and MRI Intravenous urography – dye given and xray image of KUB is taken Retrograde pyelography – uses cystoscopy to advance catheters into ureters and renal pelvis where a contrast dye is injected; looks at the collecting system cystography – evaluates reflux and injury; catheter inserted in bladder and dye injected renal angiography: dye given to assess renal arteries Cystoscopy – done with a cystoscope into urethra or a small incision; stones can be removed, urine samples taken from kidney Urodynamic studies Lab tests Know nursing prep implications!!  Blood Laboratory Tests – table 47- 8 Serum Creatinine A waste product that comes from the normal wear and tear on muscles of the body. Creatinine levels in the blood can vary depending on age, race and body size. Higher than normal levels may be an early sign that the kidneys are not working properly. As kidney disease progresses, the level of creatinine in the blood rises. 53–106 mcmol/L (men) 44–97 mcmol/L (women). Blood Urea Nitrogen (BUN) Comes from the breakdown of protein in the foods you eat. A normal BUN level is between 6–25, with 15.5 being the best value. As kidney function decreases, the BUN level rises. Common medications, including large doses of aspirin and some types of antibiotics, can also increase your BUN. Estimated Glomerular Filtration Rate(eGFR) measures of how well the kidneys are removing wastes and excess fluid from the blood. It is calculated from the serum creatinine level using age and gender with adjustment for those of African American descent. The normal value for GFR is 90 or above. A GFR below 60 is a sign that the kidneys are not working properly. Once the GFR decreases below 15, one is at high risk for needing treatment for kidney failure, such as dialysis or a kidney transplant.  Urine Laboratory tests Creatinine Clearance test: A 24-hour urine test shows how much urine your kidneys produce can give a more accurate measurement of how well your kidney are working and how much protein leaks from the kidney into the urine in one day. compares the creatinine in a 24-hour sample of urine to the creatinine level in your blood to show how much waste products the kidneys are filtering out each minute. Urinalysis (R&M): 20 mls at least Includes microscopic examination of a urine sample as well as a dipstick test. The dipstick is a chemically treated strip, which is dipped into a urine sample. The strip changes color in the presence of abnormalities such as excess amounts of protein, blood, pus, bacteria and sugar. A urinalysis can help to detect a variety of kidney and urinary tract disorders, including chronic kidney disease, diabetes, bladder infections and kidney stones. Culture and Sensitivity (C&S): 10 mls at least Placed on culture dish to grow potential microorganism causing suspect infection. Diagnostic Testing Interventions Patient teaching: provide a description of the tests and procedures in language the patient can understand Use appropriate, correct terminology Encourage fluid intake unless contraindicated Instruct patient in methods to reduce discomfort: Sitz baths, relaxation techniques Administer analgesics and antispasmodics as prescribed Assess voiding and provide instruction related to voiding practices and hygiene Provide privacy and respect Urinary Tract Infection Affect upper and lower urinary tract Inflammation of urinary tract, usually by bacterial infection (E. coli) Classified as: Complicated or uncomplicated; initial or recurrent; unresolved or bacterial persistence Table 48-2 (Predisposing factors) Common Lower UTI Symptoms Table 48-3 Emptying Symptoms Storage Symptoms Hesitancy Urgency Intermittency Incontinence Post void dribbling Retention (complete or partial) Nocturia Dysuria Nocturnal enuresis Pain Weak Stream Frequency Gerontologic Considerations & UTIs High incidence of chronic illness Frequent use of antimicrobials Presence of infected pressure ulcers Immunocompromised Cognitive impairment Immobility and incomplete emptying of bladder Use of bedpan rather than toilet  Common Nursing Interventions (CNI): Urinary Alterations Monitor urine output relative to intake (At least 0.5 ml/kg/hr) Monitor levels of BUN, creatinine, electrolytes Encourage ambulation & maximal fluid intake permitted Clean hygiene practices (wipe front to bag with women), good peri care, hand hygiene Monitoring urine for changes in color, clarity, sediment, odour Avoid indwelling catheters if possible; exercise proper care of catheters Avoid urinary tract irritants including coffee, tea, alcohol, colas, spices, Acidify the urine and provide a less favorable climate for bacterial growth if no contraindication Emphasize the importance of finishing prescribed course of medication Client and family teaching re: causes & prevention: Preventative measures: Void q 2-3 hr. when awake and before & after intercourse; wipe front to back; wear cotton underwear; avoid irritating bath gels, etc. See table 48-6: teaching guide; See table 48-4; 48-5 Lower UTI Cystitis vs. urethritis Cystitis: Urethritis: Inflammation of the urinary bladder Inflammation of the urethra Bacteria can invade the bladder Sexual transmission from an infection in the kidneys, (Trichomonas), purulent lymphatics and urethra discharge (Gonococcal) Causes include urologic invasive procedures, fecal contamination, More commonly seen in men prostatitis or BPH, pregnancy & than women sexual intercourse (honeymoon Gonorrhea attacks urethral cystitis) mucous membranes  Assessment Findings Cystitis Urethritis Fever not common Urgency Frequency Low back pain Discomfort during In male may be due to urination & spread of infection to the frequency prostate or testes Perineal and Dysuria Hematuria suprapubic pain Diagnosis based on In women a history and urinalysis will Urinalysis May experience reveals increase C&S will identify symptoms. May do a confirm the fever and chills organism urethral smear. causative organism. in WBC and RBC  Medical Management Cystitis Urethritis Antimicrobial therapy Antibiotic therapy (e.g., Septra); usually 7 Increased fluid intake days (water, cranberry juice) Cranberry juice and Avoid fluids which are UT vitamin C recommended irritants to keep bacteria from Analgesics adhering to bladder wall Warm sitz baths Good diet and plenty of rest If STI, prompt treatment  Nursing Management Cystitis Urethritis CNI CNI Instruct client on Preventive measures preventive measures Sterile/gentle technique with Void at regular 2-3h intervals catheterization & after sexual intercourse Frequent perineal care Shower rather than tub (especially if incontinent) bathe Warm sitz baths/analgesics Clean perineum with front to for pain back motion Wear cotton underwear Avoid irritating substances (e.g., bubble bath, vaginal sprays) Clinical Manifestations: Upper UTI - Pyleonephritis Acute Chronic Kidneys inflamed & enlarged/abscesses Asymptomatic or may have low grade fever, vague GI complaints, Flank pain/tender costovertebral angle increased BP, fatigue Colicky abdominal discomfort, N/V Polyuria/nocturia when tubules fail Chills, fever and malaise-systemically ill to reabsorb water efficiently Frequency, urgency and burning on urination if also have cystitis Irreversible damage occurs; renal Urine cloudy/foul odor dysfunction may not occur for 20 Leukocytosis, pyuria years or more Medical Surgical Management: Pyelonephritis see table 48.7 Acute Chronic Adequate fluid intake Antibiotics x 14 days (common for Aim is to prevent further UTI: Septra, Cipro- can persist to 6 kidney damage weeks) Surgery (nephrectomy) if Antispasmodics and anticholinergics severe hypertension Management of the pain and fever develops & other kidney has (apply heat) – NSAIDS, Antipyretics adequate function Follow-up urine cultures 2 weeks post treatment End stage renal disease Nursing Management: Pyelonephritis Common Nursing Interventions – TABLE 48-5 Encourage fluid intake 2 – 3 L daily Interstitial Cystitis Chronic, painful inflammatory disease of the bladder wall that causes disintegration of the lining and loss of bladder elasticity Believed to be associated with an autoimmune or allergic response Clinical Manifestations: Pain and UTI’s are clinical manifestations Pain is suprapubic, or entire perineal region. Pain relieved by urination Collaborative care: Dietary and lifestyle changes Medications to control symptoms Reassurance Table 48.8 Questions 1. Lower UTIs affect the _________ & __________ 2. Inflammation of the bladder is _________ 3. Inflammation of the urethra is __________. 4. Which lower UTI is most common in men? 5. Upper UTI is often called ____________. 6. It is important to increase intake of ________ with UTI’s. Urinary Incontinence Uncontrolled loss of urine that is sufficient in magnitude to be a problem. Causes of Transient Incontinence Delirium, Infection of UT, Pharmacologic, Psychological, Excessive urine production; restricted Activity, Stool Impaction (DIAPPERS) Affects 15-50% of the elderly. Up to 40% of patients in the nursing homes have some degree of UI  Urinary incontinence types – table is the48-17 inability to control the voiding of urine. stress incontinence: loss of urine when the force of pressure exerted on the bladder exceeds the support provided by the ligament and pelvic floor Urge incontinence: loss of urine resulting from an uninhibited detrusor contraction (with or without neurological dysfunction. Overflow Incontinence Reflex incontinence: loss of urine resulting from the lack of sensation (SPI) Reduced urethral function: results when the intravesicular pressure exceed the maximal urethral pressure Functional incontinence: loss of urine when the lower urinary tract is intact but other factors cause the loss (cognitive impairment) Iatrogenic incontinence: loss of urine related to medical factors (medication side effects, prolonged urinary catheterization).  Management – table 48-18, 48-19 Medical Nursing Behavioural therapy: Incontinence is reversible and fluid management, standardized treatable voiding frequency (time, prompt, habit, bladder retraining) pelvic muscle Support and encouragement exercise when client “fails” periodically at Transvaginal or transrectal electrical behavioral therapy stimulation Medication education: purpose Neuromodulation and effect Surgical: lifting and stabilizing the Pre and post op care bladder or urethra to regain the normal urethralvesical angle or Maintenance of skin integrity lengthen the urethra (women-sling; Regular “change outs” men: removal of prostate Medications: antispasotics, anticholigerics good for all except stress incontinence Urinary Retention The inability to urinate or effectively empty the bladder Acute or Chronic Acute: usually cannot void at all Chronic: cannot completely empty the bladder (retention with overflow) a large volume of residual urine Acute is seen with complete urethral obstruction, after general anesthetic, epidural anesthetic, post gyne/bladder surgery, childbirth, or the administration of certain drugs Chronic is seen with disorders such as enlarged prostate or neurologic disorders resulting in neurogenic bladder (does not get adequate nerve stimulation) Residual urine: urine retained in bladder after voiding (PVR) Assessment Findings Acute Sudden inability to void, distended bladder, lower abdominal pain and discomfort Chronic May go unnoticed (become accustomed as the bladder has stretched over time) May void frequently in small amounts or dribbling May be signs of cystitis: fever, chills, pain on urination Increased WBCs in urine Important to determine postvoid residual (PVR) Medical-Surgical Management – see table 48.21 ACUTE CHRONIC Immediate catheterization Permanent drainage with a Intermittent (in and out) urethral catheter or a Indwelling suprapubic cystostomy May need instruments Clean intermittent to dilate urethra catheterization (CIC) (preferred method) Condom catheter for men Crede voiding (applying downward pressure to bladder during voiding) Valsalva voiding (bear down with defecation; contraindicated in some clients) Urinary Retention - Nursing Care ACUTE CHRONIC Conscious client will be able to Assessment (voiding frequency, pain, etc.) verbalize discomfort of urinary Intermittent catheterization retention; some others will not (e.g., Indwelling catheter-urethral/suprapubic Alzheimer’s) Encourage fluid intake (2000-3000 mL) I&O, monitor voiding pattern ** (8 hrs unless contraindicated post-op) Especially those that acidify urine Palpate gently for a distended bladder e.g., cranberry juice Collaborate with physician regarding Emotional support/teaching catheterization (indwelling or Hygiene, perineal care, signs of UTI intermittent and type, size) Self-catheterization Catheterized q 4-6h depending on Catheter care, taping, drainage bag volume obtained below bladder level, ensure no If more than 400 mL should be kinking catheterized more often Bladder overdistention leads to loss of tone Questions 1. T/F: urinary retention can be acute or chronic. 2. It is very important to monitor _________ in a pt with retention. 3. Prolonged Urinary retention can lead to loss of ____________. 4. Which type of urinary retention may go unnoticed as the bladder stretches over time? 5. Chronic urinary retention is often caused by _________ & _________. Kidney and Ureteral Stones Stones (calculi) in the urinary tract or bladder is called urolithiasis Nephrolithiasis refers to formation of a kidney stone in the urinary tract Ureterolithiasis refers to a stone within the ureter Calculi can occur anywhere in urinary tract from kidney pelvis down Predisposing factors: calciuria, dehydration, alkaline urine, obstructive disorders causing urinary stasis, osteoporosis, prolonged immobility, gout (uric acid crystallizes in urine) Table 48-11 risk factors Kidney and ureteral stones A calculus is a precipitate of mineral salts 70-80% are mainly calcium-calciuria, excessive calcium in the urine, is a predisposing factor (immobility, water supply, excessive intake of vit D) Five categories of stones: table 48-12 Calcium phosphate, Calcium oxalate, uric acid, cysteine and struvite (mg-ammonium phosphate) Urinary Tract Calculi (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 37 Pathophysiology and Etiology Alkaline urine promotes precipitation of calcium Certain foods are restricted to small amounts if calcium stones e.g., dairy products, broccoli, oranges, apples, figs, grapes, peanut butter If uric acid stones, restrict protein foods (gout) Enlarged prostate fosters urinary stasis Cranberry juice helps maintain urine acidity Stones traumatize the walls of the UT and cause pain as severe contractions of the ureter develop to help pass the stone. If a stone blocks the passage of urine, pressure increases above the stone and urinary stasis leads to secondary infection. The retained urine distends the renal pelvis – hydronephrosis Table 48-13 nutritional therapy Clinical Manifestations – table 48- 14 Symptoms vary with size, location and cause of calculi Usually sudden, sharp, severe flank pain radiating to the suprapubic area and external genitalia- classic symptom Accompanied by renal or ureteral colic-”worst pain known to man” Pain severity inversely proportional to stone size The pain causes nausea, vomiting & shock Urinary retention or dysuria (if obstructed) Collaborative Care If stone 4mm or less, moving & no obstruction Vigorous hydration, analgesics, antimicrobial therapy, drugs that dissolve the stone or alter promoting conditions For larger stones Extracorporeal shock wave lithotripsy (ESWL) Laser lithotripsy; cystoscopy/basket extraction Surgery For larger stones, presence of obstruction, UTI, kidney damage or constant bleeding Ureterolithotomy, pyelolithotomy, nephrolithotomy (suprapubic incisions to remove stone) Methods of treating stones Nursing Care Assess/relieve pain, nausea & vomiting Monitor levels of BUN, creatinine, electrolytes Encourage ambulation & fluid intake (2000-2200 mL/day) I&O; strain urine; check for hematuria, anuria (if bilaterally obstructed) Encourage to void q 2-3 hrs/maintain patency of catheters/nephrostomy tubes Strict asepsis to prevent microbes entering urinary tract Emotional support & teaching Avoid excessive milk intake, increase acid forming foods Questions 1. A stone within the ureter is known as ____________. 2. The majority of renal calculi are made of what mineral salt? 3. The classic symptom of renal calculi is severe ________ pain that radiates to the ___________ & _____________. 4. Pts with renal calculi should be encouraged to __________ & increase ____________. 5. Pts with renal calculi must ___________ their urine. 6. Pts with renal calculi should avoid foods high in ________ but increase foods high in ______. Bladder Cancer Most common malignant tumor of the urinary tract is transitional cell carcinoma of the bladder Affects more men than women Chronic recurrent stones (often bladder) and chronic lower urinary tract infections increase risk. Bladder Cancer Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 45 Bladder Cancer RISK FACTORS CLINICAL MANIFESTATIONS Cigarette smoking Gross, painless but visible hematuria (chronic or intermittent); most Exposure to environmental common carcinogens Bladder irritability with dysuria, frequency and urgency Recurrent UTI’s Change in urinary pattern Bladder stones Pelvic or back pain if metastasis High urinary ph Dx: urine specimens for cytology, confirmed with cystoscopy and biopsy. High cholesterol intake Pelvic radiation Cancer of prostate, colon and rectum in males Management – table 48-16 Medical Nursing Transurethral resection, Pre and Post op care: expected changes in urine color cystoscopy Quit smoking, avoid alcohol Pharmacologic: Assess for UTI (Apply CNI for UTI) Opioid analgesics Stress routine urological follow- stool softeners. ups Chemotherapy (combo- with 15- to 20-minute sitz bath two to methotrexate, BCG) three times a day to promote muscle relaxation and to reduce Radiation (reduce the risk of urinary retention microextension of tumor) Listen to and provide education for fears and concerns Urinary Diversion Devices – table 48-22 Urinary catheter (not technically a diversion device): keeping drainage bag lower than bladder, choose right size of catheter, lubricant, insert far enough to prevent trauma, avoid manipulation (traumatize the urethra and bacteria invade) Suprapubic catheter: client ability to void is tested once obstruction resolved; clamped until can void, then removed Nephrostomy tube: tube from kidney to outside abdomen/flank Ileoconduit: implanting ureter into 12-cm loop of ileum to abdominal surface with attached urostomy bag, stents placed in ureters to prevent occlusion (care like any ostomy) Urinary Diversion Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 49 Urinary Diversion (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 50 Urinary Diversion (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 51 Glomerulonephritis an immune-related inflammation of the glomeruli characterized by proteinuria, hematuria, decreased urine production, and edema. The condition affects both kidneys equally. Although the glomerulus is the primary site of inflammation, tubular, interstitial, and vascular changes also occur. Glomerulonephritis is divided into a number of classifications, which may describe: (a) the extent of damage (diffuse or focal), (b) the initial cause of the disorder (e.g., systemic lupus erythematosus, scleroderma, streptococcal infection) (c) the extent of changes (minimal or widespread). Assess patient’s exposure to medications, immunizations, microbial infections, and viral infections such as hepatitis. It is also important to evaluate the patient for more generalized conditions involving immune disorders, such as systemic lupus erythematosus 48-52 Glomerulonephritis Clinical manifestations hematuria (ranging from microscopic to gross) and urinary excretion of various formed elements, including red blood cells (RBCs), WBCs, and casts. Proteinuria and elevated and creatinine levels In most cases, recovery from the acute illness is complete. However, if progressive involvement occurs, the result is destruction of renal tissue and marked renal insufficiency Glomerulonephritis Acute poststreptococcal glomerulonephritis most common in children and young adults, but all age groups can be affected. develops 5 to 21 days after an infection of the pharynx or the skin generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria. Fluid retention occurs as a result of decreased glomerular filtration. The edema appears initially around the eyes (periorbital edema), but later progresses to involve the total body as ascites or peripheral edema in the legs. HTN, abdominal/flank pain. 95% of patients with APSGN recover completely or improve rapidly with conservative management. Rapidly progressive glomerulonephritis (RPGN) is glomerular disease associated with rapid, progressive loss of renal function over days to weeks Chronic glomerulonephritis develops insidiously and progresses over many years often found coincidentally as an abnormality on a urinalysis or when elevated blood pressure is detected. It is common to find that the patient has no recollection or history of acute nephritis or any renal disorders. Glomerulonephritis Diagnosis History and physical examination BUN, serum creatinine, and albumin CBC Renal biopsy (if indicated) u/s, Ct scan Urinalysis Nursing Management: Management focuses on symptomatic relief. Rest is recommended until signs of glomerular inflammation (proteinuria, hematuria) and hypertension subside. Edema is treated by restricting sodium and fluid intake and by administrating diuretics. Severe hypertension is treated with antihypertensive medications. Dietary protein intake may be restricted. Sodium and fluid restriction corticosteroids, cytotoxic agents, dialysis Antibiotics should be given if the streptococcal infection is still present One of the most important ways to prevent the development of APSGN is to encourage early diagnosis and treatment of a sore throat and skin lesions. If streptococci are found in the culture, treatment with appropriate antibiotic therapy (usually penicillin) is essential. The patient must be encouraged to take the full course of antibiotics to ensure that the bacteria have been eradicated. Good personal hygiene is an important factor in preventing the spread of cutaneous streptococcal infections. 48-56 Renal Failure AKI-acute kidney injury; emerging term that refers to varying degrees of renal impairment Renal failure involves inability of nephrons in kidneys to maintain fluid, electrolyte and acid-base balances, remove nitrogenous waste products and perform regulatory functions Two types Acute (ARF) chronic (CRF) Develops as a consequence of various factors such as decreased blood flow, conditions which damage nephrons and obstructive disorders Acute Kidney Injury (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 58 Acute Renal Failure Complex disorder with many etiological factors and variant clinical manifestations Develops as a consequence of: prerenal (e.g., hypovolemic shock, decreased CO) diorders intrarenal (e.g., nephrotoxicity, lupus) disorder postrenal (e.g., enlarged prostrate, stones) disorders Rapid accumulation of toxic wastes occurs (azotemia) serum urea (BUN) and creatinine (CR) levels rise; BUN accumulates when protein is broken down; CR is a waste product of the muscles Serum creatinine (CR) good indicator of kidney function Client becomes oliguric and treatment directed towards correcting cause and preventing permanent damage See table 49-2 common causes Acute Renal Failure Progresses through 4 phases: 1. Initiation or Onset: Once acute kidney injury occurs S&S appear within hrs/days (initiation) 2. Maintenance : Oliguric-Anuric: Accompanied by a reduced blood flow to kidney leading to acute tubular necrosis (death of cells in collecting tubules of nephrons), CR, K, Phosphate, decreased GFR, Diuresis: gradual increase in U/O glomerular filtration has started to recover - lots of fluid loss but remain uremic 3. Recovery: return of normal renal function (3-12 months) Increased glomerular filtration rate Stabilizing or decreasing of the BUN and creatinine levels Prevention is the key! Medical/Surgical Management – table 49-3 Prevent acute renal failure Medical Management from occurring initially IV therapy Hydrate adequately Hemodialysis Treat shock/hypotension Peritoneal dialysis promptly Fluid and dietary Treat infections promptly restrictions complex/individualized In ARF, treat primary and depend on use of cause to limit renal dialysis (low/high protein, damage and ensure low Na & K, phosphorus, perfusion of renal arteries increased Ca, decreased fat if hyperlipidemia) Correct anemia (iron/vit supplements) Surgical Management: kidney transplant Potential Nursing Diagnoses Excess fluid volume: I&O; daily Activity intolerance: Provide rest weight; lung sounds; prescribed periods between activities diuretics/antihypertensives Risk for infection: V/S q4h, Imbalanced nutrition: Assess monitor for S&S, restrict contact nutritional/fluid status; small with those infectious, cath care frequent meals; iron/calcium/vit qshift, pericare qshift D; reinforce dietary restrictions Risk for electrolyte imbalances: Risk for impaired skin integrity: Monitor cardiac rhythm, E levels, Assess and maintain skin/mucous S&S of imbalances membrane integrity, hygiene; Risk for ineffective coping: frequent mouth care PC Support, counselling meals/q4h; limit bathing to 30 min, use lukewarm water, emollient to skin, avoid scratching Chronic Renal Failure The kidneys are so badly damaged that they do not adequately: remove protein by-products and electrolytes from the blood, maintain acid-base balance perform regulatory functions such as maintaining calcification of bones and producing erythropoietin (needed for RBC production). Classified into 5 stages (table 49-7) Renal insufficiency stage occurs when 75% of nephron function is lost End-stage renal disease (ESRD) when 85-90% of nephrons are lost (stage 5) Pathophysiology When a large portion of body’s nephrons are destroyed, kidney disease occurs. As nephrons die, the undamaged ones increase their work capacity so client may not show S&S even though 50% of nephron function has been lost Causes are numerous including DM, hypertension, glomerulonephritis, polycystic kidney disease, autoimmune diseases, drug induced BUN & CR rise, hyponatremia, hyperkalemia (due to decreased excretion of K+), hypocalcemia, metabolic acidosis Assessment findings – Figure 49-3 Most body systems affected as Urinary: polyuria, oliguria and anuria endocrine, regulatory and excretory functions are lost Respiratory: dyspnea, pulmonary edema Integument: Gastrointestinal: ulcerations, Uremia & uremic frost on the stomatitis, uremic fetor skin-(skin becomes excretory organ); pruritus (calcium- Neurological: depression of CNS, phosphate deposits) lethargy, fatigue, apathy, irritability, altered mental ability Hematological: Anemia, bleeding tendencies, Musculoskeletal: bone disorders, bone infection, increased risk of cancer pain, muscle cramps CV: Reproductive: infertility and decreased libido, impotence CVD leading cause of death, hypertension & fluid overload- ▪ Endocrine: hypothyroidism common CHF & LVH Electrolyte/acid-base imbalances: see previous slide Chronic Kidney Disease (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 66 Nursing Interventions & Rationales – NCP 49-1 Monitor BP, periorbital, sacral and peripheral edema, and dyspnea, which are indicators of fluid excess. - Monitor weight, intake, and output to determine the effect of treatment on volume status. -Provide appropriate diet instruction to help control edema and hypertension. -Instruct the patient and caregivers on measures instituted to treat the hypervolemia (e.g., daily weights, fluid restrictions) to help monitor and control fluid overload and related hypertension. Assess the patient for dyspnea, excess fatigue, tachycardia, palpitations, or chest pain, which are indicators of anemia. Monitor trends in hemoglobin and iron stores (e.g., ferritin, total iron-binding capacity and transferring saturation to determine the effect of treatment on anemia. Teaching Anemia Management: Provide information about the causes of CKD anemia, symptoms, treatment, benefits of treatment and potential adverse effects to increase patient knowledge and promote self-management of adherence to treatment plan. Instruct the patient to administer subcutaneous ESA to promote self-confidence and skill mastery. Discuss the importance of adhering to the medication regimen (iron and ESA) because a major reason of poor response to ESA therapy is nonadherence. Dialysis – table 49-13 Procedure for cleaning and filtering the blood Provides a substitute for kidney function when the kidneys are unable to remove waste products, maintain fluid electrolyte and acid-base balances Two Types: Hemodialysis requires transporting blood from the client through a dialyzer, a semipermeable membrane filter within a machine Peritoneal dialysis uses the peritoneum, the semipermeable membrane lining the abdomen, to filter wastes, fluid and chemicals Peritoneal Dialysis Catheter inserted through anterior abdominal wall into peritoneal cavity Commercial dialysis solution used to fill peritoneal cavity waste and excess water pass from the blood through the peritoneum to the dialysis fluid Three phases; inflow, dwell and drain. One cycle through the 3 phases called an exchange (4-6 times/day) Time for exchange varies and is individualized Peritoneal Dialysis (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 70 Peritoneal Dialysis (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 71 Peritoneal Dialysis (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 72 Peritoneal Dialysis (Cont.) Complications of peritoneal dialysis Exit-site infection Peritonitis Abdominal pain Outflow problems Hernias Lower back problems Bleeding Pulmonary complications Protein loss Carbohydrate and lipid abnormalities Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 73 Hemodialysis Need vascular access with rapid blood flow Arteriovenous fistulas (AVFs) and grafts (AVGs) and tunnelled and non-tunnelled central venous catheters (JV or subclavian) AVF preferred and created by the surgical connection of a vein and artery usually in forearm (allows vein to become much larger and more muscular) Created at least 3-4 months before dialysis starts Arterial segment used for arterial flow to dialyzer and venous segment for the reinfusion of dialyzed blood. Hemodialysis As blood moves through the dialyzer, waste products pass through the dialyzer membrane and are carried away. Blood cells too large to pass through Monitor for clotting and infection of AVF Complications include hypotension, muscle cramps, loss of blood, hepatitis, sepsis Treatments are usually for 3-5 hours at least 3 times/week Hemodialysis (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 76 Hemodialysis (Cont.) Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 77 Complications of Hemodialysis Hypotension Dysrhythmias Electrolyte and Ph imbalances as fluids and E+ rapidly leave the extracellular space Muscle cramps Loss of Blood Exsanguination can occur if blood lines separate or needles become dislodged Hepatitis Sepsis Disequilibrium Syndrome Results from CSF shifts. More likely to occur in ARF when BUN is very high. S&S includes headache, nausea and vomiting, restlessness, decreased LOC, seizures. Nursing Care Nursing assessment – fluid status (? Weight, BP, peripheral edema, heart and lung sounds) Assess condition of vascular access Temperature Skin condition Fluid gained since last treatment Vital signs every 30-60 mins What to do if hypotensive? (elevate feet) Treatment lasts 3-5 hours min 3 times a week Questions 1. T/F: Women are more affected by bladder cancer than men? 2. T/F: acute renal failure occurs rapidly? 3. T/F: Recovery from acute renal failure is possible? 4. Chronic renal failure occurs when ________ of kidney functioning is lost. 5. T/F: chronic renal failure only impacts the urinary system? Review Questions  Review Videos & Quizzes https://www.youtube.com/watch?v=oZdsv1OlhOk https://quizlet.com/151788048/medsurg-uti-flash-cards/ https://quizlet.com/164009809/med-surg-exam-3-urinary-tract-problems- flash-cards/ https://www.youtube.com/watch?v=lBdL-ugzJ9c https://quizlet.com/80495372/med-surg-test-6-types-of-incontinence-flash- cards/ https://quizlet.com/191629274/urinary-incontinence-nclex-flash-cards/ https://quizlet.com/160670949/urinary-retention-flash-cards/ https://quizlet.com/201933457/med-surg-renal-calculi-flash-cards/ https://www.youtube.com/watch?v=zoSKaV6gGxs&list=PLxMKS1J8XuXdEOEY dufV-9Mp9dESDeszZ&index=3 https://www.youtube.com/watch?v=GHshZSCbtOk https://www.youtube.com/watch?v=Hwl8WubnO-M https://quizlet.com/345927500/323-exam-5-bladder-cancer-flash-cards/