Med-Surg Exam Review #4 – Urinary & Renal
Brenda
Review of Anatomy, R-A-A
Lab values CBC, including left shift
WBC: 4,300 and 10,800 cells per cubic millimeter
RBC: generally between 4.2 to 5.9 million cells/cmm
Platelets: 150,000 to 400,000/ cmm
Shift to the Left:
• Labs reported WBC & differential in the same order (from
left to right): WBC total, bands, neutrophils, eosinophils,
basophils, lymphocytes, & monocytes.
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FALL 2010
• This is the basis for a "shift to the left."
• The 1st 3 numbers from the left (WBC total, bands, and
neutrophils) are important because the total number of
WBCs increases when you have an acute infection, & the
numbers of bands & neutrophils also increase, causing a
shift in % because, as the % of bands & neutrophils
increase, the % of the other cells must decrease.
• This then constitutes the "shift to the left."
BUN: normal levels are 7 - 20 mg/dL
• Measure of the amount of nitrogen in the blood in the
form of urea, & a measurement of renal function. Urea is a
substance secreted by the liver, & removed from blood by
the kidneys.
• A greatly elevated BUN (>60 mg/dL) generally indicates a
moderate-to-severe degree of renal failure.
• A low BUN usually has little significance, but its causes
include liver problems, malnutrition, or excessive ETOH
consumption
• When the ratio of BUN to creatinine (BUN:Cr) is greater
than 20, the patient is suspected of having pre-renal
azotemia (pathologic process is unlikely to be due to
intrinsic kidney damage)
Creatinine Level: normal is 0.8 to 1.4 mg/dL.
• Creatinine clearance: used to estimate the glomerular
filtration rate (GFR), the standard by which kidney
function is assessed.
Both serum & urine creatinine measurements are necessary
to calculate the creatinine clearance
______________________________________________________________
______________
Joana
GFR
• 1st step in urine formation
o Glomeruli filters blood to form filtrate
• Normal GFR: 125 ml/min (7.5 L/hr or 180 L/day)
o Yields 1 to 3 L/day of urine
o Controlled by BP & blood flow
• Blood, albumin, & other proteins are too large to be
filtered.
 Med-Surg Exam Review #4 – Urinary & Renal
o NOT NORMALLY FOUND IN URINE!
• African Americans have more age related decreases in
GFR than whites.
o 20% less blood flow
o Higher risk for renal failure
Drug therapy (slides 14, 15); pg 1556 -1558 in Med-Surg
txtbk
• Sulfonamides
o Trimethoprim/sulfamethoxazole (Bactrim/Septra)
o Ask patient about drug allergies, especially to sulfa
drugs, before beginning drug therapy.
o Drink a full glass of water w/ each dose & to have
an overall fluid intake of at least 3 L daily.
o Keep out of the sun or to wear protective clothing
outdoors & use a sunscreen.
o Complete the drug regimen even if the symptoms
improve/disappear sooner.
• Quinolones
o Ciprofloxacin (Cipro), Levofloxacin (Levaquin)
o Cipro: take the extended release drugs to swallow
them whole, not to crush or chew the tablets.
o Levaquin: patient should know how to take their
pulse, to monitor it twice daily while on this drug,
& to notify the prescriber if new-onset irregular
heartbeats occur.
• Penicillins
o Ampicillin, Amoxicillin (Amoxil),
Amoxicillin/clavulanate (Augmentin)
o Ask patient about allergies to penicillin before
beginning drug therapy.
o Take drug with food.
o Call prescriber if severe or watery diarrhea
develops.
o Women who takes oral contraceptives use an
additional method of BCP while taking this drug.
• Cephalosporins
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FALL 2010
o Cephalexin (Keflex), Cefadroxil (Duricef), Cefixime
(Suprax), Cefrtriaxone (Rocephin)
o Ask about drug allergies to penicillin or
cephalosporins before beginning of drug therapy.
o Call MD if severe or watery diarrhea develops.
o Complete the drug regimen even if the symptoms
improve or disappear sooner.
• Aminoglycosides
o Gentamycin, Tobramycin
o Ototoxic, nephrotoxic.
o Check trough before and peak after
• Urinary antiseptics
o Nitrofurantoin (Furadantin, Macrobid)
o Shake the bottle well before measuring the drug.
o Obtain a calibrated spoon for liquid drugs don’t use
household spoons.
o Drink a full glass of water with each dose & to have
an overall fluid intake of at least 3L daily.
• Bladder analgesics
o Phenazopyridine (Pyridium, Uristat)
o Remind patient that this drug will not treat an
infection, only the symptoms
o Take the drug with or immediately after a meal.
o Urine will turn red or orange.
• Antispasmodics
o Hyoscyamine (Anaspaz), Oxybutynin (Ditropan),
Tolterodine (Detrol)
o Notify MD if blurred vision or other eye problems,
confusion, dizziness or fainting spells, fast
heartbeat, fever, or difficulty passing urine occurs.
o Wear dark glasses in sunlight or other bright light
areas.
Urethritis
• Inflammation of the urethra, symptoms similar to UTI.
• Major cause of STDs
• Men: dysuria, discharge from meatus
o Gonococcal urethritis (GU) & nongonococcal urethritis
(NGU)
 Med-Surg Exam Review #4 – Urinary & Renal FALL 2010

• Women: similar to bacterial cystitis 1. Stress Incontinence - coughing, sneezing, laughing,

o 10-40% of women w/ urethritis eventually develop lifting, weak pelvic muscles and urethra, very common
pelvic inflammatory disease (PID) after child birth and menopause
______________________________________________________________ 2. Urge Incontinence - overactive bladder present with
______________
detrusor muscle hyperreflexia, have inability to stop
Kari
Prostatitis (think boggy, inflammation of the prostate) urine flow, sudden strong urge to void, and leak large
amounts of fluid
• Caused by e.coli, enterobact, proteus, or group d
3. Overflow Incontinence - bladder overdistention caused
streptococci
by an obstruction or impaired detrusor muscle
• 3 Types
4. Mixed Incontinence - any combination of stress, urge,
• 1. Acute Bacterial Prostatitis
or overflow incontinence
o Fever, chills, dysuria, urethral discharge,
5. Functional Incontinence - inability to get to the toilet,
boggy, tender prostate, gentle palpation of can be due to physical, cognitive, or social impairment
prostate results in discharge with WBC’s
• Greater prevalence in females, however in overflow
present
incontinence M=W
o S&S of infection as well as lower urinary tract
• Places pt. at risk for falls, altered skin integrity
symptoms such as urgency and rectal and
• Risk Factors include: obesity, dementia, immobility,
perineal pain
depression, constipation, multiple preganacies, vaginal
o Managed with antibiotics for 6 weeks
births, urinary retention, chronic cystitis, neurological
2. Chronic Bacterial Prostatitis
disorders (Alzheimer’s, stroke, Parkinsons ect.),
* occurs in elder men without systemic
medications such as diuretics, CNS depressents,
manifestations
anticholinergics, DM, surgery for GU problems, renal or
3. Nonbacterial Prostatitis
bladder disease
* normal exam
• Interventions: toileting schedule, voiding diary,
* diagnosis of exclusion
intermittent catheterization, decrease fluid intake, use
Urinary incontinence (involuntary loss of urine severe
of incontinence garments, Kegal exercises, avoid
enough to cause social or hygienic problems)
caffeine, and alcohol.
• underreported (high cost, embarissment)
MEDS: Antispasmodics, Anticholinergics, such as Oxybuynin
• urethra must relax, bladder must contract (detrusor
(Ditropan or tolterodine (Detrol)
muscle) in rhythmic and coordinated manner
Diagnostic Tests: Cystourethroscopy and Cystometrogram
• internal spinchter is involuntary (evaluation of sphincter, determines bladder capacity,
• external spinchter is voluntary compliance, and pressure, and presence of volunatery and
**** Types involuntary contractions of detrusor muscle.
Urolithiasis(renal- colic pain that radiates)

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 Med-Surg Exam Review #4 – Urinary & Renal FALL 2010

S&S excrutiationg pain radiating to back and genitalia more • Lining of kidney, renal pelvis, ureter, *bladder, urethra
intense when stone is moving or obstructing, N&V, pallor, • Multifocal, recurrent
diaphoresis, abdominal distension, U/A will show hematuria, • Causes: Exposure to chemicals, tobacco, phenacetin,
WBC, turbidity, crystals age, race
*Urinary obstruction with fever is a medical emergency!!! • Dx: U/A, CT, retrograde ureterogram, ureteroscopy,
Must treat ASAP cytology
DX: hx, S&S, KUB, no contrast CT Bladder cancer Treatment
RX calculi: many pass on their own, manage pain with opioids o TURBT (link)
(toradol), spasmolytics (Ditropan), hydrate pts, prevent
o Intravesical chemotherapy (BCG, mytomycin)
infection, strain urine, FLOMAX, Ca Channel Blockers for
 Instilling chemo agents directly into the
treatment
bladder; Side effects LOCAL, not
Types of stones -
systemic
Nephrolithiasis - stone in kidney
o Radical cystectomy with urinary diversion
Ureterolithiasis - stone in ureter
o Chemo, RT – liver, lung, bone mets
Risks include stasis (sitting urine), retention, immobility,
Urinary obstruction, prostate, calculi
urinary PH, diet, metabolic dehydration, genetics,
geographics, race, hx of prior stone • Tumor, radiation, stones, trauma, structural defects
Composition of stones (BPH), congenital
1. Calcium oxalate or calcium phosphate (75%) o Urethral stricture
2. Struvite (MG, Ammonium, phosphate) forms during o Hydronephrosis
infection (15%) o Hydroureter
3. Uric Acid (think Gout) (8%) Med - Colchine  Obstruction is lower
4. Cystine (3%) o Assessmnt
ESWL  H&P
• shock waves transmitted through liquid, moderate  U/A
sedation of General Anaesthesia, fluoroscopy or US • Pattern of urination
guided, lithotripter aimed at stone, EKG must • Flank, abdominal pain
synchronize R wave with shock wave, stent is used for • Chills, fever, malaise (UTI)
larger stones to dilate the ureter and drain urine,
• BUN, Cr, GFR
strain urine after procedure, *may see black & blue
• IVP, US, CT
marks on pt’s skin*
______________________________________________________________
______________ Hydronephrosis
Dottie o Kidney enlarges as urine collects in kidney and renal
Urothelial cancer incl. causes, treatment pelvis

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 Med-Surg Exam Review #4 – Urinary & Renal
 Permanent damage to blood vessels and
nephrons
o Book: Enlargement of the kidney caused by blockage
of urine lower in the tract and filling of the kidney with
urine
______________________________________________________________
______________
Lynn
ACUTE PYELONEPHRITIS:
• Sudden bacterial infection of the upper urinary tract:
Kidney and renal pelvis, calyces and medulla
o Spread by ascending pathogens, or by
bloodstream
o CVA tenderness
o Usually E. Coli
o Filtration, reabsorption and secretion are impaired.
• Can cause: Interstitial inflammation, tubular cell necrosis,
abscess formation, altered renal function (temporary)
o Isosthenuria: Excretion of urine whose specific
gravity is neither greater nor less than protein-free
plasma.
o Hallmark of chronic & acute renal failure in which
the kidneys lack ability to concentrate or dilute
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FALL 2010
urine & so the initial filtrate of the blood remains
unchanged despite need to conserve or excrete
water based on the body's hydration status.
• Causes:
o Infection, Hematogensis or lymphatic spread
o Kidney stones, Urinary obstruction*, Vesicoureteral
reflux*, congenital malformation, neurogenic
bladder, spinal cord injury, instrumentation,
chronic illness (DM, HTN, chronic cystitis)
• Risk Factors:
o Women >65 y/o, Older men with prostate
problems
o Chronic urinary stone disorders, Spinal cord injury
o Pregnancy, Congenital malformations
o Bladder tumors, Chronic illnesses (DM, HTN, etc)
• DX procedures
o Urinalysis/ Culture sensitivity
- Monitor for dark color, cloudy appearance,
foul odor, bacteruria, sediment, WBCs, RBCs
- Positive leukocyte esterase, positive nitrate
o WBC count with diff, WBC will shift to the left
(indicates increased number of immature cells in
response to infection.)
o Blood cultures : (+) bacteria
o Serum Creatinine/BUN/C-reactive protein, ESR: all
goes up
o Intravenous Pyelogram (IVP): may demonstrate
calculi, structural or vascular abnormalities.
- Assess for allergies! And hydration.
o Gallium scan: may indicate active pyelonephritis.
• S/S:
o VS: fever, tachycardia, tachypnea, HTN
 Med-Surg Exam Review #4 – Urinary & Renal FALL 2010

o Chills, N/V, malaise, fatigue o Antigen-antibody complexes" inflammatory

o Costerverterbral tenderness, flank and back pain
o Colicky-type abdominal pain
o Nocturia
o Asymptomatic bacteremia
• Treatment/interventions:
o Antibiotics depending on urine c/s and blood
cultures
o Increase hydration, nutrition
o Balance rest and activity
o Surgical Rx: Stent or nephrostomy, nephrectomy
(removal of kidney - last resort)
response
o Glomeruli injured  Proteinuria (loss of albumin),
hematuria, " GFR, edema, HTN
• Note: Diabetic nephropathy is the leading cause of
glomerular disease and of total kidney failure in the
United States. (see p. 1716)
• GN Infectious Causes: (Infection usually occurs prior to
renal manifestations, about 10 days prior)
o Group A beta-hemolytic strep
o Staph or gm negative sepsis

o Pyelolithotomy – removal of a stone from the o Measles, mumps, varicella, mono, CMV,
kidney coxsackievirus, Hepatitis B
o Ureteral diversion – re-implantation of the uereter
to restore bladder drainage o Infective endocarditis
o Ureteroplasty – repair or revision of the ureter
o Potentially any bacterial parasitic, fungal or viral
• Nsg Interventions:
infection
o manage pain with narcotic analgesics or NSAIDS,
administer IV abx • GN History Assessment:
o increase fluid intake to 2 to 3 L / day unless
o Recent infection
contraindicated
• Complications: Septic shock, Renal failure, Htn o Skin, upper respiratory tract
• Also see case study in slide 42
GLOMERULONEPHRITIS o Body piercings
• Def: is an INFLAMMATION of the glomerular capillaries, o Recent travel
o Usually following a streptococcal infection. It is an
immune complex dx, NOT and infection of the o Exposure to infections
kidney!

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 Med-Surg Exam Review #4 – Urinary & Renal FALL 2010

o Recent illness, surgical procedure, invasive collection period and discard the specimen.
procedure Collect all urine in a special container for
the next 24 hours and keep cool. ]
• Assessment / S/S
o Fluid volume excess symptoms: o Electrolytes (see ESKD): hyperkalemia,
hypermagnesemia, dilutional hyponatremia if urine
- Edema (face, hands), SOB, dyspnea, output is decreased
Crackles, S3 (gallop), JVD – jugular venous
distention, weight gain o Cultures if indicated

o Renal Symptoms: o Labs for immune complexes, ANA (autoimmune)

o Renal biopsy: to confirm or rule out dx.

- Changes in urinary patterns, color : smoky,
“coca-cola” colored, or coffee colored  • Interventions:
hematuria o Manage infection
- Dysuria, oliguria
o Treat fluid overload and edema
- Hematuria, casts, proteinuria
o Antihypertensive drugs
o HTN, Fatigue, anorexia, N, V, uremia (renal failure)
o Dialysis
o Elevated BUN (normal 10-20 mg/dL)
o Plasmapheresis
o Elevated serum creatinine (normal: 0.6-1.2 mg/dL)
o Balance rest & activity
o decreased Creatinine Clearance (normal: 80-140
o Daily weights
mL/min)
o Pt education
- is used to estimate the glomerular filtration
rate (GFR) -- the standard by which kidney
• Chronic Glomerulonephritis
function is assessed.
o Over 20-30 years,
o Urine specific gravity
o Kidneys atrophied, immune complexes
- [For timed urine collection, instruct the
patient to void at the beginning of the

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 Med-Surg Exam Review #4 – Urinary & Renal
o HTN, infection, inflammation, poor blood flow to
kidneys, Mild proteinuria, hematuria, HTN, fatigue,
occasional edema
o Always leads to kidney failure
• NSG Interventions:
o Abs, diuretics, vasodilators, corticosteroids, fluid
restriction, sodium restriction, protein restriction of
azotemia present.
• Complications: Renal Failure, Uremia, Pulmonary Edema,
Anemia
NEPHROTIC SYNDROME
• Is a group of symptoms, not a disease: proteinuria,
hypoalbuminemia and edema [ATI + pwpt], altered liver
activity (hyperlipidemia), HTN, Immune or inflammatory
[pwpt]
o Increased glomerular permeability. Glomerular
capillaries are damaged from immune complex
deposits, nephrotoxic antibodies, or non-
immunological insults.
o Allows larger molecules to pass through the
membrane and be excreted into urine
o Massive losses of protein into urine > 3.5 g/24 hr
o Genetic defects of GF
• Diagnostics: Urinalysis, serum lipid levels, serum albumin,
kidney biopsy. Serum BUN, Cr and GFR levels may
indicate minimal to extensive loss of kidney function. BUN
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FALL 2010
and Cr levels rise, GFR decreases with loss of kidney
function.
• RX:
o Steroids, cytoxic or immunosuppressive drugs,
o ACE inhibitors, chol. lowering drugs,
o Diet changes (replace protein),
o Mild diuretics: furosemide Lasix
o Fluid restriction, sodium restriction
o Glucocorticoids, anticoagulants
• Complications: Resp compromise, peritonitis, renal failure,
shock/death
_______________________________________________________
________________
Cheryl
Renal cell carcinoma
• adenocarcinoma of the kidney
• anemia or ryhtrocytosis (increased or decreased
erythropoietin), hypercalcemia (PTH), increased liver
enzymes, increased ESR, HTN (renin), increased hCG
metastasis= liver, lung, long bones, adrenals, other
kidney;
• Urinary tract obstruction
• Hormones: PTH produced by tumor cells->
hypercalcemia
o ^Renin levels ◊ HTN
o ^hCG levels◊ decreased libido & Change in
secondary sex characteristics
 Med-Surg Exam Review #4 – Urinary & Renal
o Increased incidence of renal cell carcinoma:
tobacco, exposure to- lead, phosphate,
cadmium
Renal biopsy
• Removal of a small piece of kidney tissue for laboratory
examination (used with glomerulonephritis)
• Provides a precise diagnosis of the condition, assists in
determining the prognosis, and helps outline the
treatment
Nephrectomy
• Kidney removal (last resort!)
• Incision on anterior and posterior of side of damaged
kidney
• Bleeding is a major concern!
• Reasons for nephrectomy: pyelonephritis, renal cell
carcinoma, renal transplant, renal trauma
______________________________________________________________
______________
Chika
Acute renal failure, including phases
• May be reversible with prompt intervention
o Prerenal
 Reduced blood flow to kidneys
- Shock, heart failure, pulmonary
embolism, anaphylaxis, pericardial
tamponade, sepsis
 Need to correct blood volume, cardiac
output, BP
 Will lead to intrarenal RF without correction
o Intrarenal/ interstitial (ARF, ATN)
 Damage to glomeruli, interstitial tissues,
tubules
 Physical, chemical, hypoxic, immunologic
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FALL 2010
- Infections, drugs__, tumors, GN,
obstruction to renal blood flow, RAS,
RVS or thrombosis, crystals
o Postrenal
 Obstruction of urine flow
- Cancer, stones, BPH, urethral
stricture, bladder atony
• Phases of ARF
o Onset Phase
 Begins with the precipitating event and
continues until oliguria (less than 400
mL/day )
develops. Lasts hours to days
o Oliguric phase
 Characterized by a urine output of 100-400
mL/day that does not respond to fluid
challenges or diuretics. Typically lasts 1 to 3
wks but can last for several weeks,
especially in older patients or those having
pre-existing renal insufficiency
o Diuretic Phase (High-Output Phase)
 Often has a prompt onset, with urine flow
increasing rapidly over a period of several
days. The diuresis can result in an output of
up to 10 liters (10,000 mL) of dilute urine
per day
o Recovery Phase (Convalescent Phase)
 The patient begins to return to normal
levels of activity. Renal function may
continue to improve for up to 12 months
after oliguric acute renal failure began. The
patient is particularly vulnerable to
additional renal injury during this time
o Labs---similar to CRF except anemia
- CT, renal US, cysto, retrograde pyelography
(r/o obstructions)
o Be knowledgeable about drug metabolism
o Fluid challenge, diuretics, CVP, PA catheter
 Med-Surg Exam Review #4 – Urinary & Renal FALL 2010

- I & O, monitor for fluid overload  Planning for end-stage renal failure
o Nutrition • Stage 5 GFR less than 15 mL/min
o Therapies  ESKD, Need renal replacement therapy
- PD or HD may be used  Excessive amounts of urea and creatinine,
- Continuous Renal Replacement Therapy – CRRT severe F&E and acid-base imbalances.
 Patient cannot tolerate a regular four- • With compensation from healthy nephrons, GFR is
hour hemodialysis treatment usually effective until 75% nephrons are lost
due to hypotension • Isosthenuria
Chronic kidney disease – review all info • Creatinine
• Progressive, irreversible kidney injury  From proteins in skeletal muscle
• Kidney function does NOT return as with ARF  Depends on diet, activity, muscle mass
• CKD ESKD  Excreted by renal tubules
 Can not survive without treatment • Urea
• Azotemia: build up of nitrogenous waste  Product of protein metabolism (varies with
• Uremia: Azotemia with clinical symptoms intake), excreted by kidneys
• Uremic syndrome: disease of infancy and early Nephrotoxic drugs
childhood and is classically characterized by the triad • NSAIDS
of microangiopathic hemolytic anemia, • Aminoglycosides
thrombocytopenia, and acute renal failure.  Gentamycin, vancomycin, tobramycin,
Stages of CKD amicasin
• Kidneys fail at organized fashion in 5 Stages  Ototoxic & Nephrotoxic (will order peak
• Stage 1 GFR 90+ mL/min & trough)
 Normal kidney function but reduced renal ______________________________________________________________
reserve ______________
 unaffected nephrons compensate, “at risk” Lori
 Stress with infection, fluid overload or Erythropoietin
dehydration can affect renal function • Slides:
• Stage 2 GFR 60-89 mL/min o Erythropoietin decrease, uremia, iron and folate
 Mild CKD loss
 Nephron damage, slight elevation of BUN/ Cr, o Epoetin Alfa (Epogen, Procrit)
uric acid, phosphorous not sensitive enough to o Bruising: Impaired platelets
define this stage. GFR best measure • ATI, pg. 432-433
• Stage 3 GFR 30-59 mL/min o Clotting/Infection of Access Site
 Moderate CKD  Use surgical aseptic technique during
 Dietary restrictions of fluid, protein and cannulation.
electrolytes needed  Avoid compression of access site/extremity.
• Stage 4 GFR 15-29 mL/min o Disequilibrium Syndrome (too rapid a decrease
 Severe CKD of BUN)

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 Med-Surg Exam Review #4 – Urinary & Renal
 Early recognition is essential. Signs include
nausea, vomiting, change in LOC, seizures
and agitation.
 Can be avoided with a slow dialysis
exchange rate, especially in older adult
clients and those being newly treated with
hemodialysis.
 Anticonvulsants/barbiturates may be
needed.
o Hypotension
 Discontinue dialysis.
 Place the client in the Trendelenburg
position.
o Anemia
 Administer prescribed medication therapy
(erythropoietin) to stimulate the production
of red blood cells.
o Infectious Diseases
 HD poses a risk for transmission of
bloodborne diseases such as HIV and
hepatitis B and C.
 Maintain sterility of equipment.
 Use standard precautions.
Hemodialysis:
• Patient can no longer be managed with drugs, diet, fluid
restriction, based on symptoms.
• Diffusion of solutes across an artificial semipermeable
membrane to remove excess fluid and waste products
and restore chemical & electrolyte balance
• Hospital or freestanding unit
• Dialysate (dialyzing solution) closely resembles human
plasma
o Clear water & chemicals, no need to be sterile but
requires special treatment, fluid warmed
o 3X wk for 4 hrs (Usually Tuesday, Thursday,
Saturday or Monday, Wednesday, Friday)
o Heparin used in machine - caution 4-6 hrs.
o Vascular access
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FALL 2010
 For flow of 200-300ml/min; temp venous
catheter
 AV fistula; artery to vein anastomosis;
needs to “mature”
o Av graft; ex: GORE TEX
o Complications; thrombosis, infection, aneurysms,
ischemia
o No BP, venipuncture, IV (PINK ARMBAND)
o Thrill, bruit
o Circulation, bleeding
o Check drug regimen esp vasoactive drugs
o Assess for hypotension, N, V, malaise
o Measure weight and BP, temp
o Dialysis disequilibrium syndrome
 Neurologic symptoms of varying severity
that are thought to be due primarily to
cerebral edema - new patients, elevated
BUN
Peritoneal Dialysis
Slides
• Silastic catheter surgically placed in abdominal cavity
for infusion of dialysis; peritoneum is semipermiable
membrane; infusion, dwell, drain; depends on
concentration of dialysate (glucose)
o Risk for peritonitis, contraindicated with adhesions
or abdominal surgery
o Can be done at home
o Hemodynamic tolerance
o Continuous abdominal peritoneal dialysis (CAPD); 7
days a wk, four x2Liters x 4-8hrs
o Continuous cycle peritoneal dialysis (CCPD); at
night via machine; 3-5 exchanges during the
night while the person sleeps. Once exchange with
a dwell time that lasts the entire day
ATI, Pg. 433
• Peritonitis (the major complication of PD)
o Maintain meticulous surgical asepsis during the
procedure
 Med-Surg Exam Review #4 – Urinary & Renal FALL 2010

• Infection (at access site) o Chemical dependency

o Maintain surgical asepsis of access site o Chronic infections: HIV, Hepatitis C
• Protein Loss o Coagulopathies
o Increase dietary intake of protein o Certain immune disorders
• Hyperglycemia (hyperosmolar dialysate) o Tobacco use
o Insulin for glycyemic control. o Morbid obesity
o Lipid therapy for triglyceride control • Lifelong immunosuppression
• Poor Dialysate Inflow or Outflow o Presnisone, cyclosporine (Neoral)
o Rotate catheter to facilitate inflow and outflow • Renal transplantation rejection
o Milk tubing to break up fibrin clot. Hyperacute
o Check tubin for kinks and closed clamps. o Within 48hrs, need to remove transplanted kidney
o Avoid constipation (high fiber, stool softeners) o Antibodies against the donor, crossmatch is done
______________________________________________________________ before every kidney transplant
______________ Acute
o 1-2 weeks, need to increase immunosuppression
o S/S: oliguria/anuria, increased BP, enlarged, tender
Diana kidney, temp>100, lethargy, elevated creatinine,
Renal transplant BUN, K levels, fluid retention
• Donors: living, non heart beating, cadaver Chronic - Months to yrs; management until dialysis
o living related donors (LRD) needed
o use human leukocyte antigen (HLA) studies Prostate cancer
(immunologic) as well as blood typing • Diagnosis
• Size of donor kidney does not matter o See BPH,
• Placed in anterior iliac fossa, non-functioning kidney may o include CT
be left in unless infected. o MRI
• Post-op renal transplant o Liver function
o large bore (Foley) catheter for accurate o Alkaline phosphatase
measurments of urine output and decompression o Bone scan as indicated
of the bladder • Treatment
o prevents strech on sutures o Watchful waiting (active survelliance)
o Hourly during the 1st 48hrs: oliguria or diuresis o DRE, PSA, Symptoms
o Pink or blood-tinged right after surgery o Hormonal therapy
o Daily weights, I&O, V/S, U/A, lytes  LH-RH agonists: luprolide acetate (Lupron),
• Increased risk/ contraindications Goserelin acetate (Zoladex), Firmagon
o Age < 2 or >70 (degarelix
o Advanced cardiac disease, peripheral vascular  Hot flashes, erectial dysfunction, decreased
disease libido, gynecomastia, Bilateral orchiectomy
o Active cancer (rare), loss of testosterone

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 Med-Surg Exam Review #4 – Urinary & Renal
• Prostate-specific antigen (PSA) levels from ATI p.1122:
elevated with BPH, prostatitis, & prostate cancer (normal
levels are <4ng/ml)
• Digital rectal exam (DRE) from ATI p.1122: physical
exam of prostate for size & consistency; Pt in a side-lying
position or bends over a table
• Transrectal ultra sound TRUS/ biopsy- diagnosis for
prostate
• Metastasis- lymph nodes, bone, liver, lung; use TNM
staging
Benign prostatic hyperplasia BPH
• Cells in glandular tissues undergo hyperplasia & enlarge
• Gland grows inward & causes bladder outlet obstrutction,
detrusor hypertrophy
• Retention with overflow-urinary incontinence
• May lead to hydroureter, hydronephrosis
• Nocturia, frequency
• LUTS: hesitancy, reduced stream, incomplete
emptying, post-void dribbling
• Hematuria
• Meds-drug therapy for BPH
o Avoid anticholinergics, antihistamines,
decongestants- theses drugs cause retention
o 5-alpha reductase inhibitor (5-ARI)
 Lower level of dihydrotestosterone (DHT) &
shrink prostate
 ED, decrease libido
 finasteride (Proscar), dutasteride (Avodart)
o Alpha-blocking agents
 Alpha-adrenergic receptors in prostatic
smooth muscle
 Tamsulosin (Flomax), Alfuzosin (Uroxatrol)
 Doxazosin (Cardura), Terazosin (Hytrin)
 ORTHOSTATIC HYPOTENSION
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Nirali
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FALL 2010
TURP incl. care of patient post-op:
• Enlarged portion of prostate removed through
resectoscope (endoscopic instrument)
o Small pieces of gland removed, may continue to
grow
• Glycine irrigation
• Regional or general anesthesia
• Large 3-way Foley 30 to 45 mL balloon
o Urge to void, pain, bladder spasms
• Dilutional hyponatremia
• CBI, traction
• Voiding
Post op Care of TURP p1717:
• Pt gets a 3 way catheter to prevent bleeding.
• Give pt anti-spasmatic drug to decrease bladder spasms
• When catheter is removed pt will feel burning when
urinating it is normal.
• Instruct pt to increase fluid intake to 2000 to 2500ml
daily. By the time of discharge pt should be voiding 150 to
200 ml of clear urine.
• Observe for complications like infection and incontinence.
• Teach pt that sexual function is not effected but
retrograde ejaculation is possible. This means that most of
the semen will flow backwards into the bladder and a little
semen will come out.
• Assess for post op bleeding the first 24 hrs. monitor urine
output and vitals q4hrs. (arterial bleeding will look like
ketchup and have clots!!!! Call surgeon!!!!!!) Amicar may
be given for bleeding.
• If the bleeding is venous then urine will be burgundy with
or without any change in vitals. Monitor H+H.
Testicular cancer:
• Most common malignancy in men 15 to 34 years of age
• Risks: Cryptorchidism, family history
• Early detection
o Testicular self-examination (TSE)
o Painless lump or swelling!!!!!!
 Med-Surg Exam Review #4 – Urinary & Renal FALL 2010

• Surgery is the main treatment for testicular cancer

o Orchiectomy
o Chemotherapy
o Can be cured
• Sperm banking
Tumor markers:
• Tumor markers for testicular cancer
o Alpha-fetoprotein (AFP)
o Beta human chorionic gonadotropin (hCG)
o Lactate dehydrogenase (LDH)
• Ultrasound, CT, MRI
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