Medsurg

NUR 216
Renal and Urologic Problems Acute and Chronic Renal Failure K. Henderson Spring 2011
CHAPTER 46
2
Nursing Management Renal and Urologic Problems
INFECTIOUS AND INFLAMMATORY DISORDERS OF THE URINARY SYSTEM
URINARY TRACT INFECTION

Classification Etiology and pathophysiology Clinical manifestations Diagnostic studies Collaborative care and drug therapy
Fig. 46-1
FOCUS ON URINARY TRACT INFECTION

6
URINARY TRACT INFECTION (UTI)

Second most common bacterial disease Most common bacterial infection in women due to shortened urethra
Can occur in upper or lower Urinary area. Flank (costo vertebral angle) pain Both are of concern
URINARY TRACT INFECTION (UTI) (CONTD)

Accounts for more than 8 million office visits per year >100,000 people hospitalized annually due to UTI
URINARY TRACT INFECTION (CONTD)
>15% patients who develop gram-negative bacteria infection die
33% of these caused by infections originating in urinary tract

Bladder and its contents are free of bacteria in majority of healthy patients Minority of healthy individuals have colonizing bacteria in bladder

Called asymptomatic bacteriuria, and does not justify treatment
10

Escherichia coli most common pathogen Counts of 105 CFU/ml or more indicate significant UTI Counts as low as 102 CFU/ml in a person with signs/symptoms are indicative of UTI If recurrent, pt. should urinate after intercourse to flush out bacteria
11

Fungal and parasitic infections can cause UTIs Patients at risk
Immunosuppressed Have diabetes Undergone multiple antibiotic courses Traveled to certain underdeveloped countries
12
CLASSIFICATION
Upper versus lower
Upper tract
Renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Example Pyelonephritis: Inflammation of renal parenchyma and collecting system Assess Costovertebral angle for upper UTI RISK FOR SEPTIC SHOCK!! Pt Fluctuates temp, cool due to lack of blood flow and hot due to fever
13
CLASSIFICATION
Upper versus lower (contd)
Lower tract
Lower urinary tract Usually no systemic manifestations Example Cystitis (inflammation of bladder wall)
14
SITES OF INFECTIOUS PROCESSES
15
CLASSIFICATION (CONTD)
Complicated versus uncomplicated
Uncomplicated
Occurs in otherwise normal urinary tract Usually only involves the bladder
16
CLASSIFICATION
Complicated versus uncomplicated (contd)
Complicated
Those with coexisting presence of Obstruction Stones Catheters Existing diabetes/neurologic disease Pregnancy-induced changes Recurrent infection
17
According to natural history
Initial infection
First or isolated Uncomplicated UTI in person who never had one or experiences one remote from a previous UTI (separated by period of years)
18
CLASSIFICATION
Natural history (contd)
Recurrent
Caused by second pathogen in a person who experienced a previous infection that was eradicated If it occurs because original infection was not eradicated, it is classified as unresolved bacteriuria or bacterial persistence
19
Unresolved bacteriuria
Occurs when
Bacteria resistant to antibiotic Drug discontinued before bacteriuria is completely eradicated Antibiotic agent fails to achieve adequate concentrations in bloodstream or urine to kill bacteria
20
Bacterial persistence
Occurs when
Bacteria develop resistance to antibiotic agent Foreign body in urinary system allows bacteria to survive
21
ETIOLOGY AND PATHOPHYSIOLOGY

Urinary tract above urethra normally sterile Defense mechanisms exist to maintain sterility/prevent UTIs
Complete emptying of bladder Ureterovesical junction competence URETHRITIS: Infection of Urethra Sx in men: Purulent discharge

22
Defense mechanisms (contd)

Peristaltic activity Acidic pH High urea concentration Abundant glycoproteins
23
ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

Alteration of defense mechanisms increases risk of contracting UTI Predisposing factors

Factors increasing urinary stasis
Examples: BPH, tumor, neurogenic bladder Examples: Catheters, calculi, instrumentation
Foreign bodies
24
Predisposing factors (contd)
Anatomic factors
Examples: Obesity, congenital defects, fistula Examples: Age, HIV, diabetes
Compromising immune response factors
25
Predisposing factors (contd)
Functional disorders
Example: Constipation Examples: Pregnancy, multiple sex partners (women)
Other factors
26
Menopause factor in incidence of UTI
Postmenopausal women have lower estrogen levels, in vaginal lactobacilli, in vaginal pH
Overgrowth of other organisms results
Low-dose intravaginal estrogen replacement may be effective in treating recurrent UTIs
27

Organisms introduced via the ascending route from the urethra and originate in the perineum Less common routes

Bloodstream Lymphatic system
28

Gram-negative bacilli normally found in GI tract common cause Urologic instrumentation allows bacteria to enter urethra and bladder
29
Contributing factor: Urologic instrumentation
Allows bacteria present in opening of urethra to enter urethra or bladder
Sexual intercourse promotes milking of bacteria from perineum and vagina
May cause minor urethral trauma
30

Rarely result from hematogenous route For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract
Obstruction of ureter Damage from stones Renal scars

31
Hospital-acquired UTI accounts for 31% of all nosocomial infections
Causes
Often: E. coli Seldom: Pseudomonas
Catheter-acquired UTIs
Bacteria biofilms develop on inner surface of catheter
32
CLINICAL MANIFESTATIONS
Symptoms related to either bladder storage or bladder emptying
Bladder storage
Urinary frequency Abnormally frequent (> every 2 hours) Urgency Sudden strong desire to void immediately Incontinence Loss or leakage or urine
33
Bladder storage (contd)

Nocturia Waking up 2 times at night to void Nocturnal enuresis Complaint of loss of urine during sleep
Bladder emptying
Weak stream Hesitancy Difficulty starting the urine stream
34
Bladder emptying (contd)

Intermittency Interruption of urinary stream while voiding Postvoid dribbling Urine loss after completion of voiding Urinary retention Inability to empty urine from bladder
35
Bladder emptying (contd)

Dysuria Difficulty voiding Pain on urination
36
CLINICAL MANIFESTATIONS (CONTD)

Urine may contain visible blood or sediment, giving cloudy appearance Flank pain, chills, and fever indicate infection of upper tract

Pyelonephritis
37
In older adults

Symptoms often absent Experience nonlocalized abdominal discomfort rather than dysuria May have cognitive impairment Less likely to have a fever
38
Patients with significant bacteriuria

May have no symptoms Nonspecific symptoms such as fatigue or anorexia
39
DIAGNOSTIC STUDIES
History and physical examination Dipstick urinalysis
Identify presence of nitrates, WBCs, and leukocyte esterase Culture and sensitivity
40
41
DIAGNOSTIC STUDIES (CONTD)
Urine for culture and sensitivity (if indicated)

Clean-catch sample preferred Specimen by catheterization or suprapubic needle aspiration more accurate Determine bacteria susceptibility to antibiotics
42
Imaging studies
IVP or abdominal CT when obstruction suspected
43
COLLABORATIVE CARE DRUG THERAPY
Antibiotics
Selected on empiric therapy or results of sensitivity testing Uncomplicated cystitis
Short-term course (1 to 3 days)
Complicated UTIs
Requires long-term treatment (7 to 14 days) Bactrim is Antibiotic of choice, if allergic, use Cipro
44
Antibiotics (contd)
Trimethoprim/sulfamethoxazole (TMP/SMX)
Used to treat uncomplicated or initial Inexpensive Taken BID E. coli resistance to TMP-SMX
45
Antibiotics (contd)
Nitrofurantoin (Macrodantin)
Given three or four times a day Long-term use Pulmonary fibrosis Neuropathies
Fluoroquinolones
Treat complicated UTIs Example: Ciprofloxacin (Cipro)
46
COLLABORATIVE CARE DRUG THERAPY (CONTD)
Urinary analgesic
Pyridium
Used in combination with antibiotics Provides soothing effect on urinary tract mucosa Stains urine reddish orange Can be mistaken for blood and may stain underclothing OTC AZO can be used Drink Cranberry juice Avoid spicy foods, acidic juices etc.
47
Urinary analgesic (contd)
Urised
Used in combination with antibiotics Used to relieve UTI symptoms Preparations with methylene blue tint urine blue or green
48
Prophylactic or suppressive antibiotics sometimes administered to patients with repeated UTIs
49
Suppressive therapy often effective on short-term basis
Limited because of antibiotic resistance ultimately leading to breakthrough infections
50
NURSING MANAGEMENT NURSING ASSESSMENT
Health history
Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer Antibiotics, anticholinergics, antispasmodics Urologic instrumentation Urinary hygiene
51
Health history (contd)

N/V, anorexia, chills, nocturia, frequency, urgency Suprapubic/lower back pain, bladder spasms, dysuria, burning on urination
52
NURSING MANAGEMENT NURSING ASSESSMENT (CONTD)
Objective Data

Fever Hematuria, foul-smelling urine, tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
53
NURSING MANAGEMENT NURSING DIAGNOSES

Impaired urinary elimination Ineffective therapeutic regimen management
54
NURSING MANAGEMENT PLANNING
Patient will have

Relief from lower urinary tract symptoms Prevention of upper urinary tract involvement Prevention of recurrence
55
NURSING MANAGEMENT NURSING IMPLEMENTATION
Health Promotion
Recognize individuals at risk

Debilitated persons Older adults Underlying diseases (HIV, diabetes) Taking immunosuppressive drug or corticosteroids Wear cotton crotched underwear Wipe the right way, DUH !
56
Health Promotion (contd)

Emptying bladder regularly and completely Evacuating bowel regularly Wiping perineal area front to back Drinking adequate fluids (15 ml/lb)
20% fluid comes from food
57
Cranberry juice or cranberry essence may help decrease risk Avoid unnecessary catheterization and early removal of indwelling catheters Aseptic technique must be followed during instrumentation procedures
58

Wash hands before and after contact Wear gloves for care of urinary system Routine and thorough perineal care for all hospitalized patients Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals
59
NURSING MANAGEMENT NURSING IMPLEMENTATION (CONTD)
Acute Intervention
Adequate fluid intake

Patient may think will worsen condition due to discomfort Dilutes urine, making bladder less irritable Flushes out bacteria before they can colonize
60
Acute Intervention (contd)
Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods
Potential bladder irritants
61
Application of local heat to suprapubic or lower back may relieve discomfort Instruct patient about drug therapy and side effects
62
Emphasize taking full course despite disappearance of symptoms Second or reduced drug may be ordered after initial course in susceptible patients
63
Instruct patient to watch urine for changes in color and consistency and decrease in cessation of symptoms Counsel that persistence of lower tract symptoms beyond treatment, onset of flank pain, or fever should be reported immediately
64
Ambulatory and Home Care
Emphasize compliance with drug regimen
Take as ordered
Maintain adequate fluids Regular voiding (every 3 to 4 hours) Void after intercourse
65
Ambulatory and Home Care (contd)

Temporarily discontinue use of diaphragm Instruct on follow-up care Recurrent symptoms typically occur 1 to 2 weeks after therapy
66
NURSING MANAGEMENT EVALUATION

Use of nonanalgesic relief measures Appropriate use of analgesics Pass urine without urgency Urine free of blood Adequate intake of fluids
67
ACUTE PYELONEPHRITIS
68
Fig. 46-2
69

Inflammation of renal parenchyma and collecting system Caused most commonly by bacteria Fungi, protozoa, or viruses infecting kidneys can also cause
70
Urosepsis
Systemic infection from urologic source Prompt diagnosis/treatment critical
Can lead to septic shock and death Septic shock: Outcome of unresolved bacteremia involving gram-negative organism
71

Usually begins with colonization and infection of lower tract via ascending urethral route Frequent causes
Escherichia coli Proteus Klebsiella Enterobacter

72
Preexisting factor usually present
Vesicoureteral reflux
Backward movement of urine from lower to upper urinary tract
Dysfunction of lower urinary tract

Obstruction from BPH Stricture Urinary stone
73

Commonly starts in renal medulla and spreads to adjacent cortex Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis
74
One of most important risk factors
Pregnancy-induced physiologic changes in urinary system
75
Mild fatigue Chills Fever Vomiting Malaise
76

Flank pain Lower urinary tract symptoms characteristic of cystitis Costovertebral tenderness usually present on affected side Manifestations usually subside in a few days, even without therapy

Bacteriuria and pyuria still persist
77
DIAGNOSTIC STUDIES
History Physical examination

Palpation for CVA pain
Laboratory tests
Urinalysis Urine for culture and sensitivity CBC with differential Blood culture (if bacteremia is suspected)
78

Ultrasound CT scan
79

Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria WBC casts indicate involvement of renal parenchyma CBC will show leukocytosis with increase in immature bands
80
Imaging studies (IVP or CT) requiring intravenous injection of contrast metals
Usually not obtained in early stages to prevent possible spread of infection
Ultrasonography of urinary system to identify anatomic abnormalities or presence of obstructing stone
81
Imaging studies also used to assess complications of pyelonephritis

Impaired renal function Scarring Chronic pyelonephritis Abscesses

82

If bacteremia is a possibility, close observation and vitals monitoring are essential Prompt recognition and treatment of septic shock may prevent irreversible damage or death
83
COLLABORATIVE CARE
Hospitalization for patients with severe infections and complications
Such as nausea and vomiting with dehydration
Signs/symptoms typically improve within 48 to 72 hours after starting therapy
84
COLLABORATIVE CARE (CONTD)
Drug therapy
Antibiotics
Parenteral in hospital to rapidly establish high drug levels
NSAIDs or antipyretic drugs

Fever Discomfort
Urinary analgesics
85

Relapses may be treated with 6-week course of antibiotics Follow-up urine culture and imaging studies
86
Reinfections treated as individual episodes or managed with long-term therapy
Prophylaxis may be used for recurrent infection
87
Health history
Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer Antibiotics, anticholinergics, antispasmodics Urologic instrumentation Urinary hygiene
88
Health history (contd)
Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination
89
NURSING MANAGEMENT NURSING ASSESSMENT (CONTD)
Objective Data

Fever Hematuria, foul-smelling urine, tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
90

Acute pain Impaired urinary elimination
91
Patient will have

Relief of pain Normal body temperature No complications Normal renal function No recurrence of symptoms
92
Health Promotion
Early treatment for cystitis to prevent ascending infections

Patient with structural abnormalities is at high risk Stress for regular medical care
93
Ambulatory and Home Care

Need to continue drugs as prescribed Need for follow-up urine culture Identification of risk for recurrence or relapse Encourage adequate fluids
94
Ambulatory and Home Care (contd)

Rest to increase comfort Low-dose, long-term antibiotics to prevent relapses or reinfections Explain rationale to enhance compliance
95

Use of nonanalgesic relief measures Appropriate use of analgesics Pass urine without urgency Urine free of blood Adequate intake of fluids
96
CASE STUDY
97
CASE STUDY
27-year-old female with urgency to urinate, frequent urination, and urethral burning during urination Symptoms began 48 hours ago
98
CASE STUDY (CONTD)
Urine has strong odor and cloudy appearance History of recurring urinary tract infections since 22 years of age when she got married
99
CASE STUDY (CONTD)
Allergic to penicillin Temperature 98.6 F orally
Blood pressure 114/64 mm Hg
100
CASE STUDY (CONTD)
Urinalysis results

Color: dark yellow pH: 6.5 Nitrates: positive Leukocytes: large amount Trace occult blood Urine culture: E. coli >106 CFU/ml
Sensitivity to ampicillin, nitrofurantoin, ciprofloxacin, cephalexin, TMP-SMX
101
DISCUSSION QUESTIONS
1.
What type of urinary tract infection does she probably have?

Why might she be having recurring infections?
2.
102
DISCUSSION QUESTIONS (CONTD)

3.
What is the priority of care for her? What teaching should be done with her?
4.
103
INTERSTITIAL CYSTITIS/PAINFUL BLADDER SYNDROME

Collaborative care and drug therapy Nursing management: Interstitial cystitis/painful bladder syndrome For Tx: avoid acidic foods and caffeinated beverages. DMSO drug used to desensitize bladder therefore reducing pain
104
GLOMERULONEPHRITIS
Etiology and pathophysiology Clinical manifestations
105
ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS

Clinical manifestations and complications Diagnostic studies
106
NURSING AND COLLABORATIVE MANAGEMENT: ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS
107
GOODPASTURE SYNDROME
Nursing
and collaborative management: Goodpasture syndrome
108
RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS
109
CHRONIC GLOMERULONEPHRITIS
110
NEPHROTIC SYNDROME
Etiology and clinical manifestations Collaborative care Nursing management: Nephrotic syndrome
111
OBSTRUCTIVE UROPATHIES
112
Fig. 46-3
113
Fig. 46-4
114
URINARY TRACT CALCULI
Etiology and pathophysiology
Types
Clinical manifestations Diagnostic studies
Collaborative care

Endourologic procedure Lithotripsy Surgical therapy Nutritional therapy

115
Fig. 46-5
116
Fig. 46-6
117
NURSING MANAGEMENT RENAL CALCULI

Nursing assessment Nursing diagnoses Planning Nursing implementation Evaluation
Clots, stones and strictures can obstruct renal system backing up urine causing toxicity cuz it is held in renal pelvis and introduced back to bloodstream. KIDNEY STONES ARE VERY PAINFUL!!
118
STRICTURES

Ureteral strictures Urethral stricture Manifestation of Kidney stones:

Unilateral PAIN! Dx by X-ray Tx: break it up, increased fluids collect stones to identify source, do this by straining urine. Staghorn or round shaped stones, staghorn not passed easily, surgical removal. Hemorrhage post surgery can occur. Watch for decreased BP. Drug of choice for pain during passing is IV Morphine. If uric acid stone, avoid sardines, organ meats, chicken, salmon, crab. See boxP1171 (purine) 119
Tx: Extracorpeal shock-wave lithotripsy:P1172 To help avoid recurrence of renal stones increase fluid to 3000 mL per day.
120
RENAL VASCULAR PROBLEMS
121
Kidneys need to be profussed or adequate removal of waste will not occur!
NEPHROSCLEROSIS: Only Sx will be Hypertension P1175
Polycystic Kidney Disease:
Cysts cause blockages and do not allow proper function of kidneys it is decrased.
Any drugs including NSAIDs, that are metabolized in Liver should be avoided. Tx is Kidney Transplant
122
RENAL ARTERY STENOSIS
123
RENAL VEIN THROMBOSIS
124
HEREDITARY RENAL DISEASES
125
POLYCYSTIC KIDNEY DISEASE

Clinical manifestations Collaborative care
126
Fig. 46-7
127
Fig. 46-8
128
URINARY TRACT TUMORS
129
KIDNEY CANCER
Clinical manifestations and diagnostic studies Nursing and collaborative management: Kidney cancer
130
Fig. 46-9
131
BLADDER CANCER
Clinical manifestations and diagnostic studies
Nursing
and collaborative management: Bladder cancer

Surgical therapy Radiation therapy and chemotherapy Intravesical therapy Risk factors: Hair dyes, cigarette smoking, chronic abuse of analgesics.
132
Hematuria is Sx, Tx for Bladder cancer: Transurethral resection with fulguration P 1179 If passing clots post surgery, have them come in ASAP!
133
Fig. 46-10
134
URINARY INCONTINENCE AND RETENTION

Diagnostic studies Collaborative care: Urinary incontinence
Drug therapy Surgical therapy Types: Stress incontinence: when you cough or sneeze, you pee your pants Tx: Drug therapy with Ditropan, Kegel exercises Diagnostic studies for urinary retention: Bladder scan to estimate how many mL pt. has in bladder
135
NURSING MANAGEMENT URINARY INCONTINENCE
Collaborative care: Urinary retention
Drug therapy Surgical therapy
136
NURSING MANAGEMENT URINARY RETENTION
137
INSTRUMENTATION
Urethral catheterization Ureteral catheters Suprapubic catheters Nephrostomy tubes Intermittent catheterization Wash catheter with soap and water after each use. Catheter can be used for up to 1 week.
138
Fig. 46-11
139
SURGERY OF THE URINARY TRACT
140
RENAL AND URETERAL SURGERY

Preoperative management Postoperative management
Urine output Respiratory status Abdominal distention

Laparoscopic nephrectomy
141
URINARY DIVERSION
Incontinent urinary diversion: making a fake bladder out of Colon, watch for hitting vagal nerve!P1180 Continent urinary diversions Orthotropic bladder substitution Ostomy is an option, so urine is diverted to constantly drain into Ostomy Bag.P1190
Will not make new pouch if bladder needs to rest, or diverticuli in colon prevents use.
142
Fig. 46-12
143
Fig. 46-13
144
Fig. 46-14
145
NURSING MANAGEMENT URINARY DIVERSION

Preoperative management Postoperative management
146
Fig. 46-15
147
Fig. 46-16
148
CHAPTER 47
149
Nursing Management Acute Renal Failure and Chronic Kidney Disease
ACUTE RENAL FAILURE:

KIDNEYS RAPIDLY LOSING ABILITY TO FX

Etiology and pathophysiology Clinical course

Initiating phase Oliguric phase
Urinary changes Fluid volume excess
Metabolic acidosis
Sodium balance Potassium excess Hematologic disorders Calcium deficit and phosphate excess Waste product accumulation Neurologic disorders
150
Fig. 47-1
151
Fig. 47-2
152
Fig. 47-3
153
ACUTE RENAL FAILURE (CONTD)
Clinical course (contd)
Diuretic phase Recovery phase
Diagnostic studies Collaborative care
Nutritional therapy Causes: (pre renal): shock Tumor in kidney, chemicals, liver failure
154
NURSING MANAGEMENT ACUTE RENAL FAILURE P1197

Nursing assessment
Nursing diagnoses
Planning Nursing implementation

Health promotion Acute intervention Ambulatory and home care
Evaluation
Fluid Volume decrease occurs in which stage?
Metabolic Acidosis can occur Peak T waves on EKG, QRS affected how?
155
After Oliguric Phase comes Diuretic stage Monitir BUN Creatinin levels and watch for SHOCK! Can take up to 12 mos to stabalize. Tx: cardiac output! And make sure adequate flow to kidneys.
Put
pt. on restriction of fluids. Therapy can be used to Tx. can be treated with glucose and P1201
Drug
Hyperkalemia Pt.
on low Protein diet according to Pt. status. Increase carbs and fats to
prevent
Ketosis.
Pt should avoid NSAIDs they worsen Renal Function
Clinical manifestations Table P1201
156
GERONTOLOGIC CONSIDERATIONS ACUTE RENAL FAILURE
157
FOCUS ON CHRONIC KIDNEY DISEASE

158
CHRONIC KIDNEY DISEASE (CKD)
Involves progressive, irreversible loss of kidney function
159
CHRONIC KIDNEY DISEASE (CONTD)
Defined as either presence of
Kidney damage
Pathologic abnormalities Markers of damage Blood, urine, imaging tests
Glomerular filtration rate (GFR)
<60 ml/min for 3 months or longer
160
Disease staging based on decrease in GFR
Normal GFR 125 ml/min, which is reflected by urine creatinine clearance Last stage of kidney failure
End-stage renal disease (ESRD) occurs when GFR <15 ml/min
161

Up to 80% of GFR may be lost with few changes in functioning of body Remaining nephrons hypertrophy to compensate Result is a systemic disease involving every organ
162

Each year 70,000 people die from causes related to renal failure 40 million Americans are at risk for CKD Number of patients with ESRD is expected to reach 660,000 by 2010
163
Leading causes of ESRD

Diabetes Hypertension
164
Result of retained substances

Urea Creatinine Phenols Hormones Electrolytes Water Other substances
165
Uremia
Syndrome that incorporates all signs and symptoms seen in various systems throughout the body
166
MANIFESTATIONS OF CHRONIC UREMIA
167 Fig. 47-5
Copyright 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
CLINICAL MANIFESTATIONS URINARY SYSTEM
Polyuria

Results from inability of kidneys to concentrate urine Occurs most often at night Specific gravity fixed around 1.010
168
CLINICAL MANIFESTATIONS URINARY SYSTEM (CONTD)

Oliguria
Occurs as CKD worsens

Urine output <40 ml per 24 hours
Anuria
169
CLINICAL MANIFESTATIONS METABOLIC DISTURBANCES
Waste product accumulation
As GFR , BUN and serum creatinine levels
BUN Not only by kidney failure but by protein intake, fever, corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and headaches occur
170
Waste product accumulation (contd)
Serum creatinine and creatinine clearance are more accurate indicators of kidney function than BUN
171
CLINICAL MANIFESTATIONS METABOLIC DISTURBANCES (CONTD)
Defective carbohydrate metabolism
Caused by impaired glucose use
From cellular insensitivity to the normal action of insulin
172
Defective carbohydrate metabolism (contd)
Patients with diabetes who become uremic may require less insulin than before onset of CKD Insulin dependent on kidneys for excretion
173
CLINICAL MANIFESTATIONS METABOLIC DISTURBANCES (CONTD)
Elevated triglycerides
Hyperinsulinemia stimulates hepatic production of triglycerides Altered lipid metabolism
Levels of enzyme lipoprotein lipase
Important in breakdown of lipoproteins
174
CLINICAL MANIFESTATIONS ELECTROLYTE/ACIDBASE IMBALANCES
Potassium
Hyperkalemia
Most serious electrolyte disorder in kidney disease Fatal dysrhythmias
175
CLINICAL MANIFESTATIONS ELECTROLYTE/ACIDBASE IMBALANCES
Potassium
Hyperkalemia (contd)
Results from decreased excretion by kidneys, breakdown of cellular protein, bleeding metabolic acidosis, food intake, medications
176
ELECTROLYTE/ACIDBASE IMBALANCES (CONTD)
Sodium

May be normal or low Because of impaired excretion, sodium is retained
Water is retained Edema Hypertension CHF
177
Clinical Manifestations
Electrolyte/AcidBase Imbalances (Cont d) Calcium and phosphate alterations
Magnesium alterations
178
Clinical Manifestations
Electrolyte/AcidBase Imbalances (Cont d) Metabolic acidosis
Results from
Inability of kidneys to excrete acid load (primary ammonia) Defective reabsorption/regeneration of bicarbonate
179
Hematologic System Anemia

Due to production of erythropoietin
From of functioning renal tubular cells
Bleeding tendencies
Defect in platelet function
180
Hematologic System (contd) Infection
Changes in leukocyte function Altered immune response and function Diminished inflammatory response
181
Hematologic System (contd) Increased incidence of cancer

Lung Breast Uterus Colon Prostate Skin
182

Cardiovascular System Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis
183

Respiratory System Kussmaul respiration Dyspnea Pulmonary edema Uremic pleuritis
184
Respiratory System (contd) Pleural effusion Predisposition to respiratory infections Depressed cough reflex Uremic lung
185

Gastrointestinal System Every part of GI is affected
Due to excessive urea

Mucosal ulcerations Stomatitis
186
Gastrointestinal System (contd) Every part of GI is affected (contd)
Due to excessive urea (contd)

Uremic fetor (urinous odor of breath) GI bleeding Anorexia N/V
187

Neurologic System Expected as renal failure progresses
Attributed to
nitrogenous waste products Electrolyte imbalances Metabolic acidosis Axonal atrophy Demyelination of nerve fibers
188
Neurologic System (contd) Altered mental ability Seizures Coma Dialysis encephalopathy Peripheral neuropathy
189
Neurologic System (contd) Restless leg syndrome Muscle twitching Irritability Decreased ability to concentrate
190

Musculoskeletal System Renal osteodystrophy
Syndrome of skeletal changes Result of alterations in calcium and phosphate metabolism
Weaken bones, increase fracture risk
Two types associated with ESRD:

Osteomalacia Osteitis fibrosa
191
Musculoskeletal System (contd) Metastatic calcifications
Muscles, lungs, skin, GI tract, eyes
192
RENAL OSTEODYSTROPHY
Fig. 47-6
193

Integumentary System Most noticeable change

Yellow-gray discoloration of the skin
Due to absorption/retention of urinary pigments
Pruritus Uremic frost Dry, pale skin
194
Integumentary System (contd) Dry, brittle hair Thin nails Petechiae Ecchymoses
195

Reproductive System Infertility

Experienced by both sexes
Decreased libido Low sperm counts Sexual dysfunction
196

Endocrine System Manifestations of hypothyroidism Thyroid function may yield low to low-normal levels of T3 and T4
197

Psychologic changes Personality and behavioral changes Emotional ability Withdrawal Depression
198
DIAGNOSTIC STUDIES
History and physical examination Laboratory tests

BUN Serum creatinine Creatinine clearance Serum electrolytes Protein-creatinine ratio (first morning void)
199
DIAGNOSTIC STUDIES
Laboratory tests (contd)

Urinalysis Urine culture Hematocrit Hemoglobin
Renal ultrasound Renal scan
200

Renal scan CT scan Renal biopsy
201
COLLABORATIVE CARE
Conservative therapy Correction of extracellular fluid volume overload or deficit Nutritional therapy Erythropoietin therapy Calcium supplementation, phosphate binders
202

Antihypertensive therapy Measures to lower potassium Adjustment of drug dosages to degree of renal function
203

Drug Therapy Hyperkalemia

IV insulin
IV glucose to manage hypoglycemia
IV 10% calcium gluconate Sodium bicarbonate

Shift potassium into cells Correct acidosis
204
COLLABORATIVE CARE
Drug Therapy (contd) Hyperkalemia (contd)
Sodium polystyrene sulfonate (Kayexalate)

Cation-exchange resin Resin in bowel exchanges potassium for sodium
205
COLLABORATIVE CARE
Drug Therapy (contd) Hyperkalemia (contd)
Sodium polystyrene sulfonate (Kayexalate) (contd)

Evacuates potassium-rich stool from body Educate patient that diarrhea may occur due to laxative in preparation
206

Drug Therapy Hypertension
Weight loss Lifestyle changes Diet recommendations Sodium and fluid restriction

207
COLLABORATIVE CARE
Drug Therapy (contd) Hypertension (contd)
Antihypertensive drugs
Diuretics -Adrenergic blockers Calcium channel blockers
208
COLLABORATIVE CARE
Drug Therapy (contd) Hypertension (contd)
Antihypertensive drugs (contd)

Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blocker agents
209
COLLABORATIVE CARE
Drug Therapy (contd) Renal osteodystrophy
Phosphate intake restricted to <1000 mg/day
210
COLLABORATIVE CARE
Drug Therapy (contd) Renal osteodystrophy (contd)
Phosphate binders
Calcium carbonate (Tums) Bind phosphate in bowel and excreted Sevelamer hydrochloride (Renagel) Lowers cholesterol and LDLs
211
COLLABORATIVE CARE
Phosphate binders (contd)

Should be administered with each meal Side effect: Constipation
212
COLLABORATIVE CARE
Supplementing vitamin D
Calcitriol (Rocaltrol) Serum phosphate level must be lowered before administering calcium or vitamin D
213
COLLABORATIVE CARE
Controlling secondary hyperparathyroidism
Calcimimetic agents Cinacalcet (Sensipar)
Sensitivity of calcium receptors in parathyroid glands
Subtotal parathyroidectomy
214

Drug Therapy Anemia
Erythropoietin
Epoetin alfa (Epogen, Procrit) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3 weeks Side effect: Hypertension
215
COLLABORATIVE CARE
Drug Therapy (contd) Anemia (contd)
Iron supplements
If plasma ferritin <100 ng/ml Side effect: Gastric irritation, constipation May make stool dark in color
216
COLLABORATIVE CARE
Drug Therapy (contd) Anemia (contd)
Folic acid supplements

Needed for RBC formation Removed by dialysis
Avoid blood transfusions
217

Drug Therapy Dyslipidemia
Goal
Lowering LDL below 100 mg/dl Triglyceride level below 200 mg/dl
Statins
HMG-CoA reductase inhibitors Most effective for lowering LDL
218
COLLABORATIVE CARE
Drug Therapy (contd) Dyslipidemia (contd)
Fibrates
Fibric acid derivatives Most effective for lowering triglycerides Can also decrease HDLs
219

Drug Therapy Complications
Drug toxicity
Digitalis Antibiotics Pain medication (Demerol, NSAIDs)
220

Nutritional Therapy Protein restriction

0.6 to 0.8 g/kg body weight/day Intake depends on daily urine output
Water restriction
221

Nutritional Therapy Sodium restriction
Diets vary from 2 to 4 g depending on degree of edema and hypertension Sodium and salt should not be equated Patient should be instructed to avoid high-sodium foods Salt substitutes should not be used because they contain potassium chloride
222
COLLABORATIVE CARE
Nutritional Therapy (contd) Potassium restriction
2 to 4 g High-potassium foods should be avoided
Oranges Bananas Tomatoes Green vegetables
223
COLLABORATIVE CARE
Nutritional Therapy (contd) Phosphate restriction
1000 mg/day Foods high in phosphate
Dairy products
Most foods high in phosphate are also high in calcium
224

Complete history of any existing renal disease, family history Long-term health problems Dietary habits
225

Excess fluid volume Risk for injury Imbalanced nutrition: Less than body requirements Grieving Risk for infection
226
Overall goals
Demonstrate knowledge and ability to comply with therapeutic regimen Participate in decision making Demonstrate effective coping strategies
227
Overall goals (contd)
Continue with activities of daily living within psychologic limitations
228
Health promotion
Identify individuals at risk for CKD

History of renal disease Hypertension Diabetes mellitus Repeated urinary tract infection
Regular checkups and changes in urinary appearance, frequency, and volume should be reported
229
Acute intervention

Daily weight Daily BPs Identify signs and symptoms of fluid overload Identify signs and symptoms of hyperkalemia Strict dietary adherence
230
Acute intervention (contd)
Medication education Motivate patients in management of their disease
231
Ambulatory and home care
When conservative therapy is no longer effective, HD, PD, and transplantation are treatment options Patient/family need clear explanation of dialysis and transplantation
232

Maintenance of ideal body weight Acceptance of chronic disease No infections No edema Hematocrit, hemoglobin, and serum albumin levels in acceptable range
233
GERONTOLOGIC CONSIDERATIONS
About 35% of ESRD patients are 65 years of age or older Most common diseases leading to renal failure in the older adult
Hypertension Diabetes
234
GERONTOLOGIC CONSIDERATIONS (CONTD)

Diminished cardiopulmonary function Bone loss Immunodeficiency
235

Altered protein synthesis Impaired cognition Altered drug metabolism
236
Most common cause of death in the elderly ESRD patient

Cardiovascular disease (MI, stroke) Withdrawal from dialysis
237
CASE STUDY
238
CASE STUDY
35-year-old male began to notice weakness with activities such as walking distances or running Also began experiencing tingling all over his body, particularly in his hands and feet
239
CASE STUDY (CONTD)
Symptoms progressed over 4 months, with 10 pounds of weight lost with no decline in appetite
240
CASE STUDY (CONTD)
Increased urinary output with normal frequency Strong thirst at night
Sought medical help because he was afraid he was getting diabetes
241
CASE STUDY - HISTORY
History reveals grandmother and aunt have diabetes with no family history of renal disease At 5 years of age, he was admitted to the hospital for hematuria Urinary protein 4+ BUN 31 mg/dl Hb 11.6 Was diagnosed with acute glomerulonephritis
242
CASE STUDY - HISTORY
At 11 years of age, he was admitted to the same hospital with gross hematuria
Albuminuria 4+ BUN 10.5 Hb 15.7 Diagnosed with recurring acute glomerulonephritis
243
CASE STUDY
He has had no follow-up medical care after that hospitalization until being admitted to the hospital currently
244
CASE STUDY (CONTD)
Current lab values

Potassium 6.0 mEq/L BUN 110 mg/dl Creatinine 12 mg/dl Hct 20% Hb 6 gm/dl
245
DISCUSSION QUESTIONS
1.
Why would his symptoms seem similar to diabetes? Why is he developing chronic renal failure so many years after his primary diagnosis?
2.
246
DISCUSSION QUESTIONS (CONTD)

3.
What is the priority of care for him?

What patient teaching should be done with him?
4.
247
DIALYSIS
General principles of dialysis
248
Fig. 47-7
249
PERITONEAL DIALYSIS
Catheter placement Dialysis solutions and cycles Peritoneal dialysis systems
Automated peritoneal dialysis Continuous ambulatory peritoneal dialysis
250
Fig. 47-8
251
Fig. 47-9
Fig. 47-10
253
Fig. 47-11
254
Fig. 47-12
255
PERITONEAL DIALYSIS (CONTD)
Complications of peritoneal dialysis

Exit site infection Peritonitis Abdominal pain Outflow problems Hernias Lower back problems Bleeding
256
PERITONEAL DIALYSIS (CONTD)
Complications of peritoneal dialysis (contd)

Pulmonary complications Protein loss Carbohydrate and lipid abnormalities Encapsulating sclerosing peritonitis and loss of ultrafiltration
Effectiveness of and adaptation to chronic peritoneal dialysis
257
HEMODIALYSIS
Vascular access sites
Shunts Internal arteriovenous fistulas and grafts Temporary vascular access
258
Fig. 47-13
259
Fig. 47-14
260
Fig. 47-15
261
HEMODIALYSIS (CONTD)
Dialyzers Procedure

Settings for hemodialysis
262
Fig. 47-16
263
Fig. 47-17
264
HEMODIALYSIS (CONTD)
Complications of hemodialysis
Hypotension
Muscle cramps Loss of blood Hepatitis Sepsis Disequilibrium syndrome
Effectiveness of and adaptation to hemodialysis

265
CONTINUOUS RENAL REPLACEMENT THERAPY
266
Fig. 47-18
267
KIDNEY TRANSPLANTATION
Recipient selection
Histocompatibility studies
Donor sources
Live donors
Deceased donors
Surgical procedure
Live donor
Kidney transplant recipient
268
Fig. 47-19
269
NURSING MANAGEMENT KIDNEY TRANSPLANT RECIPIENT

Preoperative care Postoperative care
Live donor Recipient
270
KIDNEY TRANSPLANTATION (CONTD)

Immunosuppressive therapy Complications of transplantation
Rejection Infection Cardiovascular disease Malignancies Recurrence of original renal disease Corticosteroid-related complications
271
GERONTOLOGIC CONSIDERATIONS CHRONIC KIDNEY DISEASE
272

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NUR 216

Nursing Management Renal and Urologic Problems

INFECTIOUS AND INFLAMMATORY DISORDERS OF THE URINARY SYSTEM

URINARY TRACT INFECTION

FOCUS ON URINARY TRACT INFECTION

URINARY TRACT INFECTION (UTI)

URINARY TRACT INFECTION (UTI) (CONTD)

URINARY TRACT INFECTION (CONTD)

>15% patients who develop gram-negative bacteria infection die

33% of these caused by infections originating in urinary tract

URINARY TRACT INFECTION (CONTD)

Called asymptomatic bacteriuria, and does not justify treatment

URINARY TRACT INFECTION (CONTD)

URINARY TRACT INFECTION (CONTD)

Upper versus lower

Upper versus lower (contd)

SITES OF INFECTIOUS PROCESSES

Complicated versus uncomplicated

Complicated versus uncomplicated (contd)

According to natural history

Natural history (contd)

ETIOLOGY AND PATHOPHYSIOLOGY

ETIOLOGY AND PATHOPHYSIOLOGY

Defense mechanisms (contd)

Peristaltic activity Acidic pH High urea concentration Abundant glycoproteins

ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

Factors increasing urinary stasis

Examples: BPH, tumor, neurogenic bladder Examples: Catheters, calculi, instrumentation

ETIOLOGY AND PATHOPHYSIOLOGY

Predisposing factors (contd)

Examples: Obesity, congenital defects, fistula Examples: Age, HIV, diabetes

Compromising immune response factors

ETIOLOGY AND PATHOPHYSIOLOGY

Predisposing factors (contd)

Example: Constipation Examples: Pregnancy, multiple sex partners (women)

ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

Menopause factor in incidence of UTI

Postmenopausal women have lower estrogen levels, in vaginal lactobacilli, in vaginal pH

Overgrowth of other organisms results

Low-dose intravaginal estrogen replacement may be effective in treating recurrent UTIs

ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

Bloodstream Lymphatic system

ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

Contributing factor: Urologic instrumentation

Allows bacteria present in opening of urethra to enter urethra or bladder

Sexual intercourse promotes milking of bacteria from perineum and vagina

May cause minor urethral trauma

ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

Obstruction of ureter Damage from stones Renal scars

ETIOLOGY AND PATHOPHYSIOLOGY (CONTD)

Hospital-acquired UTI accounts for 31% of all nosocomial infections

Bacteria biofilms develop on inner surface of catheter

Symptoms related to either bladder storage or bladder emptying

Bladder storage (contd)

Bladder emptying (contd)

Bladder emptying (contd)

CLINICAL MANIFESTATIONS (CONTD)

CLINICAL MANIFESTATIONS (CONTD)

CLINICAL MANIFESTATIONS (CONTD)

Patients with significant bacteriuria

May have no symptoms Nonspecific symptoms such as fatigue or anorexia

DIAGNOSTIC STUDIES (CONTD)