Renal System

Sheryll Joy Lopez-Calayan, RN, MAN

RENAL FAILURE


loss of kidney function acute renal failure and chronic renal failure S/Sx retention of wastes, the retention of fluids, and the inability of the kidneys to regulate electrolytes Prerenal causes include intravascular volume depletion, decreased cardiac output, and vascular failure secondary to vasodilation or obstruction Intrarenal causes include tubular necrosis, nephrotoxicity, and alterations in renal blood flow Postrenal causes include obstruction of urine flow between the kidney and urethral meatus and bladder neck obstruction

Acute renal failure (ARF)

sudden loss of kidney function; caused by renal cell damage from ischemia or toxic substances abrupt and can be reversible Hypoperfusioncell death decompensation in renal function prognosis cause and the condition of the client Near-normal or normal kidney function may resume gradually

 Causes
Infection Renal artery occlusion Obstruction Acute kidney disease Dehydration Diuretic therapy Ischemia from hypovolemia, heart failure, septic shock, or blood loss Toxic substances such as medications, particularly antibiotics

 Oliguric phase

8 to 15 days, longer the duration less chance of recovery Sudden drop in urine output; urine output less than 400 mL/day Urine specific gravity of 1.010 to 1.016 Anorexia, nausea, and vomiting Hypertension Decreased skin turgor Pruritus Tingling of the extremities Drowsiness progressing to disorientation to coma Edema Dysrhythmias Signs of congestive heart failure (CHF) and pulmonary edema Signs of pericarditis Signs of acidosis

 Diuretic phase
Urine output rises slowly then diuresis occurs Excessive urine output indicates recovery of damaged nephrons Hypotension Tachycardia Improvement in level of consciousness (LOC)

 Recovery phase (convalescent)

A slow process; complete recovery may take 1 to 2 years Urine volume is normal Increase in strength Increase in LOC BUN is stable and normal Client can develop chronic renal failure

Chronic renal failure (CRF)

progressive loss and ongoing deterioration in kidney function that occurs slowly over a period of time Has stages, is irreversible, and results in uremia or end-stage renal disease affects all of the major body systems and requires dialysis or kidney transplant to maintain life Hypervolemia can occur owing to the inability of the kidneys to excrete sodium and water, or hypovolemia can occur owing to the inability of the kidneys to conserve sodium and water

 Causes
May follow ARF Renal artery occlusion Chronic urinary obstruction Recurrent infections Hypertension Metabolic disorders Diabetes mellitus Autoimmune disorders

 Assessment

Anorexia and nausea Headache Weakness and fatigue Hypertension Confusion and lethargy, followed by convulsions and coma Kussmaul respirations Diarrhea or constipation Muscle twitching and numbness of the extremities Decreased urine output Decreased urine specific gravity Proteinuria Anemia Azotemia Fluid overload and signs of heart failure Uremic frost: a layer of urea crystals from evaporated perspiration that appears on the face, eyebrows, axilla, and groin in clients with advanced uremic syndrome

Implementation Monitor vital signs Monitor urine and I & O (hourly in ARF) Monitor weight, noting that an increase of 0.5 to 1 pound daily indicates fluid retention Monitor BUN, creatinine, and electrolyte values Monitor for acidosis and treat with sodium bicarbonate as prescribed Assess urinalysis for protein, hematuria, casts, and specific gravity Monitor LOC Assess for signs of infection, since the client may not demonstrate a temperature or an increased white blood cell (WBC) count Assess for dysrhythmias, since a potassium level above 6 mEq/L will cause peaked T waves and a widened QRS complex Monitor for fluid overload; assess lungs for rales and rhonchi Monitor for edema

moderate protein intake (to decrease the workload on the kidneys) and a high-carbohydrate, low-potassium, and low-phosphorus Restrict sodium intake as prescribed, based on the electrolyte level intake 400 mL to 1000 mL plus measured urinary output Administer sodium polystyrene sulfonate (Kayexalate) to lower the potassium level as prescribed X nephrotoxic medications, such as antibiotics, which may be prescribed Prepare the client for dialysis if prescribed

What is the most common cause of chronic renal failure? NIDDM.

Special problems in renal failure

Hypertension
Failure of the kidneys to maintain homeostasis of the blood pressure Monitor vital signs Maintain fluid and sodium restrictions as prescribed Administer propranolol (Inderal), a betaadrenergic antagonist, as prescribed, which decreases rennin release (rennin causes vasoconstriction)

 Hypervolemia
Monitor vital signs Monitor I & O and weight Monitor for edema Monitor electrolytes Monitor for hypertension Monitor for CHF and pulmonary edema Enforce fluid restriction Avoid the administration of IV fluids Administer diuretics as prescribed Instruct the client to avoid foods with sodium

 Hypovolemia
Monitor vital signs Monitor I & O and weight Monitor electrolytes Monitor for hypotension Monitor for dehydration Provide replacement therapy based on the electrolyte results Provide sodium supplements as prescribed, depending on the electrolyte value

 Potassium retention
Monitor vital signs and apical rate Monitor potassium level Monitor for dysrhythmias (peaked T waves and widened QRS complex) indicating hyperkalemia Provide a low-potassium diet Administer medications as prescribed to lower the potassium level Prepare the client for dialysis

 Phosphorus retention

Phosphorus rises and calcium drops, which leads to stimulation of parathyroid hormone, causing bone demineralization Treatment is aimed at lowering serum phosphorus levels aluminum hydroxide - bind phosphorus in the intestine and allow the phosphorus to be eliminated meals and not with other medications, because they bind medications in the intestinal tract stools softeners and laxatives - constipating Enforce phosphorus restriction in the diet

 Low calcium
because of the high phosphorus level and inability of the diseased kidney to activate vitamin D The absence of vitamin D causes a poor absorption of calcium from the intestinal tract Monitor calcium level Administer calcium supplements as prescribed Administer activated vitamin D as prescribed

 Metabolic acidosis
The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis alkalyzers - sodium bicarbonate Note that clients with CRF adjust to low bicarbonate levels and do not become acutely ill

 Anemia
diseased kidney decreased secretion of erythropoietin Monitor hemoglobin and hematocrit epoetin alfa (Epogen) - stimulate the production of RBCs folic acid (vitamin B9) X ORAL nausea and vomiting blood transfusions if prescribed, decrease the stimulus to produce RBCs Monitor bleeding soft toothbrush stool softeners X acetylsalicylic acid (aspirin) -excreted by kidneys; prolong bleeding time

 GI bleeding
Urea ammonia by the intestinal bacteria ammonia -mucosal irritant that causes ulceration and bleeding hemoglobin and hematocrit levels Monitor stools for occult blood

 Infection and injury

need to be monitored and avoided because tissue breakdown causes increased potassium levels X urinary catheters and provide strict asepsis during insertion and catheter care avoid persons with infections Administer antibiotics as prescribed, monitoring for nephrotoxic effects

 Pruritis
Urate crystals are excreted through the skin to rid of excess wastes This deposit of crystals is called uremic frost, and it is seen in advanced stages of renal failure Monitor for skin breakdown, rash, and uremic frost Provide good skin care and oral hygiene Avoid the use of soaps Administer antipruritics as prescribed

 Muscle cramps
Occur in the extremities and hands and can be due to electrolyte imbalances Monitor electrolytes Administer electrolyte replacements as prescribed Administer heat and massage as prescribed

 Ocular irritation
Calcium deposits in the conjunctiva cause burning and watering of the eyes Administer medications to control the calcium and phosphate levels as prescribed Administer lubricating eye drops

 Insomnia and fatigue

The diseased kidneys cause a buildup of wastes, causing fatigue in the client Provide adequate rest periods Administer mild CNS depressants as prescribed

 Neurological changes
The buildup of active particles and fluids causes changes in the brain cells and leads to confusion and impairment in decision-making ability Provide a safe and hazard-free environment Use side rails as needed Provide a calm and restful environment Provide comfort measures and backrubs

Psychosocial problems: Monitor the client for psychological problems such as depression, anxiety, suicidal behavior, denial, dependence/independence conflict, and changes in body image

HEMODIALYSIS
The diffusion of dissolved particles
from one fluid compartment into another across a semipermeable membrane The clients blood flows through one fluid compartment into another fluid compartment

 Functions of hemodialysis
Cleanses the blood of accumulated waste products Removes the by-products of protein metabolism, such as urea, creatinine, and uric acid Removes excessive fluids Maintains or restores the bodys buffer system Maintains or restores electrolyte levels

 Principles of hemodialysis

The semipermeable membrane is made of a thin, porous cellophane The pore size of the membrane allows small particles to pass through, such as urea, creatinine, uric acid, and water molecules Proteins, bacteria, and blood cells are too large to pass through the membrane The clients blood flows into dialyzer; the movement of substances occurs from the blood to the dialysate Diffusion: The movement of particles from an area of greater concentration to one of a lesser concentration Osmosis: The movement of fluids across a semipermeable membrane from an area of lesser concentration of particles to an area of greater concentration of particles Ultrafiltration: The movement of fluid across a semipermeable membrane as a result of an artificially created pressure gradient

Dialysate bath Composed of water and major electrolytes The dialysate need not be sterile because bacteria are too large to pass through; however, the dialysate must meet specific standards, and water treatment systems are used to ensure a safe water supply

 Implementation
vital signs laboratory values before, during, and after dialysis Assess the client for fluid overload prior to the procedure Assess patency of the blood access device Weigh the client before and after the procedure to determine fluid loss Hold antihypertensives and other medications that can affect the BP prior to the procedure, as prescribed Hold medications that could be dialyzed off, such as water-soluble vitamins and certain antibiotics Monitor for shock and hypovolemia during the

ACCESS FOR HEMODIALYSIS

Subclavian and femoral catheter
A subclavian (subclavian vein) or femoral (femoral vein) catheter may be inserted for short-term or temporary use in ARF May be used until a fistula or graft matures or develops, or when the client has fistula or graft access failure because of infection or clotting

 Implementation
Assess insertion site for hematoma, bleeding, dislodging, and infection Do not use these catheters for any reason other than dialysis Maintain an occlusive dressing

 Subclavian vein catheter

Is usually filled with heparin and capped to maintain patency between dialysis treatments The catheter should not be uncapped The catheter may be left in place for up to 6 weeks if complications do not occur

 Femoral vein catheter

The client should not sit up more than 45 degrees or lean forward, or the catheter may kink and occlude Assess extremity for circulation, temperature, and pulses Prevent pulling or disconnecting of the catheter when giving care Use an IV control pump with microdrip tubing if a heparin infusion is prescribed

External arteriovenous shunt (AV shunt)

surgical insertion of two Silastic cannulas into an artery and a vein in the forearm or leg, to form an external blood path U shape; blood flows artery shunt vein A tube leading to the membrane compartment of the dialyzer is connected to the arterial cannula Blood fills the membrane compartment and flows back to the client by way of a tube connected to the venous cannula When dialysis is complete, the cannulas are clamped and reattached to form their U shape

 Advantages
Can be used immediately following creation No venipuncture is necessary for dialysis External danger of disconnecting or dislodging Risk of hemorrhage, infection, or clotting Skin erosion around the catheter site can occur

Disadvantages

Implementation
Avoid wetting the shunt A dressing is completely wrapped around the shunt and kept dry and intact Cannula clamps need to be available at the clients bedside Do not take a blood pressure, draw blood, place an IV, or administer injections in the shunt extremity patent if it is warm to touch Auscultate and palpate for a bruit, although a bruit may not be heard and is not always felt with the shunt Notify the physician immediately if signs of clotting, hemorrhage, or infection occur

 Signs of clotting
Fold back the dressing Fibrin-white flecks noted in the tubing The separation of serum and cells The absence of a previously heard bruit Coolness of the tubing or extremity Client complaints of a tingling sensation

Internal arteriovenous fistula (AV fistula)

chronic dialysis clients Created surgically by anastomosis of an artery in the arm to a vein; this creates an opening or fistula between a large artery and a large vein The flow of arterial blood into the venous system causes the veins to become engorged (matured or developed) Maturity takes about 1 to 2 weeks and is required before the fistula can be used, so that the engorged vein can be punctured with a large-bore needle for the dialysis procedure Subclavian or femoral catheters, peritoneal dialysis, or an external AV shunt can be used for dialysis while the fistula is maturing or developing

 Advantages

Disadvantages

Since the fistula is internal- less danger of clotting and bleeding used indefinitely Decreased incidence of infection No external dressing is required freedom of movement Cannot be used immediately after insertion Needle insertions are required for dialysis Infiltration of the needles during dialysis can occur and cause hematomas An aneurysm can form in the fistula Arterial steal syndrome can develop (too much blood is diverted to the vein, and arterial perfusion to the hand is compromised) CHF can occur from the increased blood flow in the venous system

Internal arteriovenous graft (AV graft)

chronic dialysis clients who do not have adequate blood vessels for the creation of a fistula Gore-Tex or a bovine (cow) carotid artery is used to create an artificial vein for blood flow The procedure involves the anastomosis of the graft of the artery, a tunneling under the skin, and anastomosis to a vein The graft can be used 2 weeks after insertion Complications of the graft include clotting, aneurysms, and infection

 Advantages

Disadvantages

Since the graft is internal, there is less danger of clotting and bleeding The graft can be used indefinitely Decreased incidence of infection No external dressing is required Allows freedom of movement
Cannot be used immediately after insertion Needle insertions are required for dialysis Infiltration of the needles during dialysis can occur and cause hematomas An aneurysm can form in the graft Arterial steal syndrome can develop (too much blood is diverted to the vein, and arterial perfusion to the hand is compromised) CHF can occur from the increased blood flow in the venous system

 Implementation for AV fistula and AV graft

Do not measure a blood pressure, draw blood, place an IV, or administer injections in the fistula or graft extremity Monitor for clotting Complaints of tingling or discomfort in the extremity Inability to palpate a thrill or auscultate a bruit over the fistula or Monitor for arterial steal syndrome Palpate pulses below the fistula or graft, and monitor for hand
graft

Monitor for infection Monitor lung and heart sounds for signs of CHF Notify the physician immediately if signs of clotting, infection, or arterial steal syndrome occur

swelling as an indication of ischemia Note temperature and capillary refill of the extremity

PERITONEAL DIALYSIS

The peritoneum is the dialyzing membrane (semipermeable membrane) and substitutes for kidney function during kidney failure Works on the principles of diffusion and osmosis, and the dialysis occurs via the transfer of fluid and solute from the bloodstream through the peritoneum large and porous, allowing solutes and fluid to move via an osmotic gradient from an area of higher concentration in the body at an area of lower concentration in the dialyzing fluid The peritoneal cavity is rich in capillaries; therefore, it provides a ready access to blood supply

 Contraindications to peritoneal dialysis

Peritonitis Recent abdominal surgery Abdominal adhesions Impending renal transplant

 Dialysate-sterile The higher the glucose concentration, the

greater the amount of fluid removed during an exchange Heparin- prevent clotting of the catheter Antibiotics: Prophylactic - prevent peritonitis Insulin: - diabetes mellitus

ACCESS FOR PERITONEAL DIALYSIS

siliconized rubber catheter 3 to 5 cm below the umbilicus - avascular

and has less fascial resistance The catheters are tunneled under the skin to stabilize the catheter and reduce the risk of infection 1 to 2 weeks - ingrowth of fibroblasts and blood vessels into the cuffs of the catheter, which fix the catheter in place and provide an extra barrier against dialysate leakage and bacterial invasion

Peritoneal dialysis infusion

One infusion (inflow), dwell,and outflow =one exchange open system - risk of infection Inflow: 1 to 2 liters of dialysate 10 to 20 minutes Dwell time: The amount of time in the cavity; prescribed by the physician Outflow: Fluid drains out of body by gravity into the drainage bag

 Implementation before treatment

Monitor vital signs Obtain weight Have the client void, if possible Assess electrolyte and glucose levels

Implementation during treatment

Monitor for signs of infection Monitor for respiratory distress, pain, or discomfort Monitor for signs of pulmonary edema Monitor for hypotension and hypertension Monitor for malaise, nausea, vomiting Assess the catheter site dressing for wetness or bleeding Do not allow dwell time to extend hyperglycemia Turn the client from side to side or have the client sit upright if the flow is slow to start Monitor outflow, which should be a continuous stream after the clamp is opened Monitor outflow for color and clarity Monitor I & O accurately If outflow is less than inflow, the difference is equal to the amount absorbed or retained by the client during dialysis and should be counted as intake

A physician orders sodium polystyrene sulfonate (Kayexalate). What would be the most likely reason for administering this drug?

Elevated level.

serum

potassium

What precautions should you take if a patients potassium level rises to a dangerous level? Place the patient on a cardiac monitor and prepare for the possibility of cardiac arrest.

You are caring for a patient with chronic renal failure. You have been instructed not to take blood pressure in her right arm. What would be the reason for this? The patient most likely has an AV fistula or an external cannula in her right arm for dialysis. The blood pressure should never be taken in that arm because of the damage it could cause to the fistula.

During dialysis, regional anticoagulation is used. What does this mean? Heparin is infused for coagulation into the dialysis machine to decrease the chance of blood clot formation by the dialysis machine.

What medication is given to normalize the clotting time in the patient receiving dialysis?

Protamine.

Is milk of Magnesia an appropriate over-thecounter medication for patients with chronic renal failure? Why or why not? No. It can lead to magnesium toxicity since the kidneys are not able to excrete it.

What techniques can you use if the return of the dialysate solution is less than the amount infused?
Since return is accomplished by gravity, having the patient turn from side to side or gentle pressure on the abdomen may help increase dialysate drainage.

CYSTITIS/URINARY TRACT INFECTIONS (UTI)

Inflammation of the bladder from infection or

obstruction of the urethra The most common causative organisms are

More common in women - shorter urethra &

Escherichia coli, Enterobacter, Pseudomonas, and Serratia

close to the rectum Sexually active and pregnant women are most vulnerable to cystitis

What would be a priority nursing action if disequilibrium syndrome occurs during dialysis? Slow the dialysis. rate of

What symptoms would a patient exhibit if disequilibrium syndrome was occurring during dialysis? Nausea, vomiting, headache, dizziness, seizures, and confusion.

 Assessment

Frequency and urgency Burning on urination Voiding in small amounts Inability to void Incomplete emptying of the bladder Lower abdominal discomfort or back discomfort Cloudy, dark, foul-smelling Hematuria Bladder spasms Malaise, chills, fever Nausea and vomiting

 Implementation
culture and sensitivity antibiotics force fluids up to 3000 mL a day, especially if the client is taking a sulfonamide, crystals in concentrated urine. Maintain an acid urine pH (5.5) - acid ash diet; Note that if the client is prescribed an aminoglycoside, a sulfonamide, or nitrofurantoin (Macrodantin), the actions of these medications are diminished by acidic urine

What is the most common bacteria involved in urinary tract infections?

Escherichia coli.

What is the purpose of Phenazopyridine (Pyridium) in the treatment of cystitis?

It is used as an analgesic the relieves some of the discomfort associated with cystitis.

URETHRITIS
inflammation of the urethra commonly

associated with sexually transmitted diseases (STD), and may be seen with cystitis In men, it is most often caused by gonorrhea or chlamydial infection In women, it is most often caused by feminine hygiene sprays, perfumed toilet paper or sanitary napkins, spermicidal jellies, UTIs, or changes in the vaginal mucosal lining

 Assessment Males

Females

Frequency Urgency Nocturia Difficulty voiding Discharge from the penis Frequency Urgency Nocturia Painful urination Difficulty voiding Lower abdominal discomfort

Implementation Encourage fluids sitz baths If stricture =dilation + instillation of an antiseptic solution Instruct the client to avoid intercourse until the symptoms subside or treatment of the STD is complete Instruct the female client to avoid the use of perfumed toilet paper or sanitary napkins and feminine hygiene sprays- AVOID CAUSES

URETERITIS AND PYELONEPHRITIS

Ureteritis An inflammation of the renal pelvis and the

parenchyma, commonly caused by bacterial invasion Acute pyelonephritis bacterial contamination of the urethra or following an invasive procedure of the urinary tract Chronic pyelonephritis chronic obstruction with reflux or chronic disorders

Escherichia coli

 Assessment
Fever and chills Nausea Flank pain on the affected side Costovertebral angle (CVA) tenderness Headache Muscular pain Dysuria Frequency and urgency Cloudy, bloody, or foul-smelling urine Increased white blood cells in the urine

GLOMERULONEPHRITIS
caused by an immunological reaction proliferative and inflammatory changes

within the glomerular structure Destruction, inflammation, and sclerosis of the glomeruli of both kidneys occur The inflammation of the glomeruli results from an antigen-antibody reaction produced from an infection elsewhere in the body Loss of kidney function develops

 Causes

Types Acute: Occurs 2 to 3 weeks after a streptococcal

Immunological or autoimmune diseases Previous/ history of Streptococcal infection, group A betahemolytic History of pharyngitis or tonsillitis 2 to 3 weeks prior to symptoms

infection Chronic: Can occur after the acute phase or slowly over time Complications
Heart failure Hypertensive encephalopathy Pulmonary edema

 Assessment

Gross hematuria Dark, smoky, cola-colored or red-brown urine Proteinuria - excessive foam in the urine high specific gravity Low urinary pH Oliguria or anuria Headache Chills and fevers Fatigue and weakness Anorexia, nausea, and vomiting Pallor Edema in the face, periorbital area, feet, or generalized Shortness of breath, ascites, pleural effusion, and CHF Abdominal or flank pain Hypertension Reduced visual acuity Increased BUN and creatinine levels Increased antistreptolysin O titer (used to diagnose disorders caused by streptococcal infections)

What four clinical findings indicates acute glomerulonephritis (GN)?

Oliguria, hypertension, pulmonary edema, and urine sediment containing red blood cells, white blood cells, protein, and red blood cell casts.

POLYCYSTIC KIDNEY DISEASE

A cystic formation and hypertrophy
of the kidneys, cystic rupture, infection, the formation of scar tissue, and damaged nephrons There is no known way to arrest the progress of the destructive cysts The ultimate result of this disease is renal failure

 Types
Infantile polycystic disease: An inherited autosomal recessive trait that results in the death of the infant within a few months after birth Adult polycystic disease: An autosomal dominant trait that results in end-stage renal disease

 Assessment
Flank, lumbar, or abdominal pain Fever and chills UTIs Hematuria, proteinuria, pyuria Calculi Hypertension Palpable abdominal masses and enlarged kidneys

 Implementation
Hematuria-indicates cyst rupture Increase sodium and water intake because sodium loss rather than retention occurs Provide bed rest if ruptured cysts and bleeding occur Prepare the client for percutaneous cyst puncture for relief of obstruction, or for draining an abscess Prepare the client for dialysis or renal transplantation Encourage the client to seek generic counseling

UROLITHIASIS AND NEPHROLITIHIASIS

Calculi or stones - most frequent site is the kidneys calculi pain, obstruction, and tissue trauma, with secondary hemorrhage and infection Kidneys, ureters, and bladder (KUB) film, intravenous pyelogram (IVP), computed tomography (CT) scan, and renal ultrasonography will determining treatment stone analysis - type of stone treatment Urolithiasis - urinary stones; urinary calculi - ureters Nephrolithiasis - kidney stones; renal parenchyma When a calculus occludes the ureter and blocks the flow of urine, the ureter dilates, producing a condition known as hydroureter If the obstruction is not removed, urinary stasis results in infection, impairment of renal function on the side of the blockage, and resultant hydronephrosis and irreversible kidney damage

 Causes

Family history of stone formation Diet high in calcium, vitamin D, milk, protein, oxalate, purines, or alkali A high intake of purine-rich food Obstruction and urinary stasis Dehydration Use of diuretics, which can cause volume depletion UTIs and prolonged urinary catherization Immoblization Hypercalcemia and hyperparathyroidism Elevated uric acid, such as in gout

 Assessment
Renal colic - lumbar region and radiates around the side and down toward the testicle in men, and to the bladder in the women Ureteral colic -radiates toward the genitalia and the thigh Sharp, severe pain of sudden onset Dull, aching kidney Nausea and vomiting, pallor, and diaphoresis during acute pain Urinary frequency with alternating retention Signs of a UTI Low-grade fever RBCs, WBCs, and bacteria in the urinalysis Hematuria

 Implementation

Monitor I & O Assess for fever, chills, and infection Monitor for nausea, vomiting, and diarrhea Force fluids up to 3000 mL/day, unless contraindicated, to facilitate the passage of the stone and prevent infection Strain all urine for the presence of stones Send stones to the laboratory for analysis Provide warm baths and heat to the flank area analgesics - relieve pain IV fluids - increase the flow of urine and facilitate the passage of the stone relaxation techniques - relieving pain diet specific to the stone composition pH depending on the type of stone Turn and reposition immobilized clients

 Stone composition Calcium phosphate stones

Caused by supersaturation of urine with calcium and phosphate - acid ash foods- calcium stones -alkaline chemistry decrease intake of foods high in calcium and phosphate to reduce urinary calcium content, and to avoid excess vitamin D intake to prevent stones from forming

 Calcium oxalate stones

Caused by supersaturation of urine with calcium and oxalate acid ash - calcium stones - alkaline chemistry decreasing intake of foods high in calcium avoiding oxalate food sources to reduce urinary oxalate content and the formation of stones Oxalate-rich food sources include tea, almonds, cashews, chocolate, cocoa, beans, spinach, and rhubarb

 Struvite stones
triple phosphate stones - magnesium and ammonium phosphate urea splitting by bacteria Struvite stones - alkaline urine acid ash foods limit high-phosphate foods - dairy products, red and organ meats, and whole grains, to reduce urinary phosphate content

 Uric acid stones

excess dietary purine or gout Uric acid stones - acidic urine alkaline ash foods and decreased intake of purine sources, such as Organ meats, graves, red wines, and sardines, to reduce urinary purine content Allopurinol (Zyloprim) may be prescribed to lower uric acid levels

 Cystine stones
cystine crystal formation Cystine stones - acidic urine alkaline ash foods low intake of methionine, an essential amino acid that forms cystine, avoid meat, milk, cheese, and eggs encouraging fluid intake up to 3 liters a day unless contraindicated, to help dilute the urine and prevent cystine crystals from forming

What should be a priority nursing goal for a patient with renal calculi? Relieve pain. the patients

What is the purpose of administering the drug allopurinol (Zyloprim) to a patient? It reduces uric acid formation responsible for gout and some types of kidney stones.

HYDRONEPHROSIS
Distention of the renal pelvis and
calices, caused by an obstruction of normal urine flow The urine becomes trapped proximal to the obstruction The causes include calculus, tumors, scar tissue, and kinks in the ureter

 Assessment
Hypertension Headache Flank pain Electrolyte imbalances

 Implementation
Monitor vital signs frequently Monitor for fluid and electrolyte imbalances, including dehydration after the obstruction is relieved Monitor for diuresis, which can lead to fluid depletion Monitor daily weights Monitor urine for specific gravity, albumin, and glucose Administer fluid replacement as prescribed

HYDRONEPHROSIS
Distention of the renal pelvis and
calices, caused by an obstruction of normal urine flow The urine becomes trapped proximal to the obstruction The causes include calculus, tumors, scar tissue, and kinks in the ureter

 Assessment
Hypertension Headache Flank pain Electrolyte imbalances

 Implementation
Monitor vital signs frequently Monitor for fluid and electrolyte imbalances, including dehydration after the obstruction is relieved Monitor for diuresis, which can lead to fluid depletion Monitor daily weights Monitor urine for specific gravity, albumin, and glucose Administer fluid replacement as prescribed

SURGICAL MANAGEMENT OF KIDNEY STONES

Cystoscopy no incision
stone may be manipulated and dislodged by the procedure Catheters are left in place for 24 hours to drain the urine trapped proximal to the stone and to dilate the ureter

Extracorporeal shock wave lithotripsy (ESWL)

Fluoroscopy is used to visualize the stone no incision Ultrasonic waves are delivered through a bath of warm water
to the areas of the stone to disintegrate it Stones are passed in the urine within a few days Preprocedure: NPO for 8 hours prior to procedure Postprocedure

Monitor vital signs Monitor I & O Monitor for bleeding Monitor for pain and signs of urinary obstruction Instruct the client to increase fluid intake to wash out the stone fragments Inform the client that ambulation is important

Percutaneous lithotripsy bladder, ureter, or kidney invasive procedure An ultrasonic wave is aimed at the stone to break it into fragments May be performed via cytoscopy or nephroscopy No incision - cystoscopy; small flank incision - nephroscopy indwelling catheter A nephrostomy tube - administer chemical irrigations to break up the stone; 1 to 5 days drink 3000 to 4000 mL of fluid per day following the procedure monitor for complications of infection, hemorrhage, and extravasation of fluid into the retroperitoneal cavity

 Ureterolithotomy
open surgical procedure, performed if lithotripsy is not effective location of the stone is in the ureter Incision into the ureter is made through a lower abdominal or flank incision to remove the stone The client may have a Penrose drain, a ureteral stent catheter, and an indwelling bladder catheter

 Pyelolithotomy
flank incision into the kidney is made to remove stones from the renal pelvis A large flank incision is required The client will have a Penrose drain and an indwelling catheter

 Nephrolithotomy
Incision into the kidney is made to remove stones from the renal pelvis A large flank incision is required The client may have a nephrostomy tube and an indwelling catheter

What is the purpose of administering the drug allopurinol (Zyloprim) to a patient? It reduces uric acid formation responsible for gout and some types of kidney stones.

What serum blood test is the best indicator of renal function?

Serum creatinine.

What is the best way to obtain a urine specimen from a patient with a Foley catheter? Clean the drainage tube collection site with betadine and aspirate urine from the drainage tube using a sterile needle.

Following a cystoscopy, a patient complains a bladder spasms. You note that his urine is pink tinged. What should you do? Monitor him, but keep in mind that these are normal symptoms following a cystoscopy.

Following a prostatectomy, a patient has continuous bladder irrigation. What guideline should you use as an indicator for the rate of irrigation? If the return is bright red, the flow should be increased. This would indicate the presence of blood and a rapid flow is needed to prevent blood clot formation.

What should be done with the urine of a patient with suspected renal or urethral calculi? Strain for calculi.

What is the most common nosocomial infection?

Urinary tract infection.

JEWELS ON FLUIDS AND ELECTROLYTES

NURSING PRIORITY
Sodium is the major electrolyte that affects fluid balance. Where goes the sodium, so goes the water.

ISOTONIC SOLUTIONS

Use to expand extracellular fluid volume

and for intravascular dehydration. Solutions a. D5W: 5% dextrose in water b. 0.9% NaCl (Normal saline solution) c. Lactated Ringers solution May be used to dilute medications or to keep the vein open

NURSING PRIORITY
In D5W the dextrose is metabolized rapidly, leaving free water to be absorbed. It does not replenish electrolytes; it is contraindicated for clients with head injuries and should be used with caution in children due to the potential for increase in intracranial pressure.

NURSING PRIORITY
Daily weight is the most reliable indicator of fluid loss or gain in all clients, regardless of age. Accurate daily weight: same time each day, preferably before breakfast, same scales, same clothing.

What is the number one cause of UTIs?

E. coli. Other causative agents are also Gramnegative.

What electrolyte abnormality is commonly associated with the transfusion of packed red blood cells? Hypocalcemia secondary to citrate toxicity. Citrate, when rapidly infused, binds ionized calcium and therefore decreases the calcium level. Hyperkalemia may also develop with rapidly packed red blood cell transfusion, especially if the patient is in renal failure or if the blood products are old.

What electrolyte disorder is associated with hypercalcemia?

Hypokalemia.

What complication may arise when citrate is present in stored blood? Citrates binds calcium which can induce hypocalcemia in a patient receiving the blood.

What drug will most rapidly decrease K+?

Calcium chloride IV (1-3 minutes).

What metabolic conditions will potentiate the toxic cardiac effects on digoxin?
Hypokalemia hypercalcemia. and

What is the initial treatment for hypercalcemia? Saline and furosemide.

What vital sign might be affected with hypermagnesemia?

Hypermagnesemia causes hypotension because it relaxes vascular smooth muscle. Deep tendon reflexes may disappear.

Antacids containing Magnesium may cause:

Diarrhea.

Antacids containing Aluminum may cause:

Constipation.

What findings presentation of a rapidly glomerulonephritis?

mark the patient with progressive

Hematuria (most common), edema (periorbital), HTN, ascites, pleural effusion, rales, and anuria.

What should you be aware of when taking vital signs in a patient with an arteriovenous fistula?

Do not take the blood pressure in the arm containing the fistula.

A client in renal failure is prescribed polystyrene sulfonate (Kayexalate). What is the most likely reason for administering this drug? Elevated potassium levels.

What are some of the symptoms of disequilibrium syndrome in a patient with chronic renal failure?

Hypertension, headache, confusion, nausea, and vomiting.

What is the physiological reason for Disequilibrium Syndrome?

During dialysis, excess solutes are cleared from the blood at a faster pace than they can diffuse from the bodys cells into the circulatory system.

What type of diet does a client need to follow with chronic renal failure?

A low protein, potassium diet.

low

What is the only crystalloid fluid compatible with packed RBCs?

Normal saline.

Which of the following foods contains the highest amount of potassium: corn flakes, whole wheat bread, milk, a baked potato, or an orange? A baked potato.

Approximately how many millimeters of fluid are in one packed red blood cells? 250.

What is the primary reason for an IV ordered at a keep open rate? To provide an emergency route for drugs.

How can you determine of the fluid replacement therapy administered to a dehydrated patient was effective? The urine output is the most sensitive indicator of hydration. It should amount to 30 cc per hour minimum for adequate hydration.

In the absence of renal or cardiac problems, what should be the normal urine output in a patient who is adequately hydrated?
30-35 ml/hour or greater.

What common invasive device is a frequent cause of sepsis in the elderly?

The Foley catheter.

Which type of diuretic will facilitate sodium excretion and potassium retention?
A potassium sparring diuretic such as spironolactone (Aldactone).

What is common reaction?

the most transfusion

A febrile, nonhemolytic reaction.

How often should a peripheral IV site be change?

Every third day.

How long should one unit of packed RBCs be administered? Over 2-4 period. hour

What should be done if a blood transfusion is not started within 30 minutes after the blood has been received from the blood bank?

Return it to the blood bank, because the refrigeration facilities on a typical nursing unit are inadequate for storing blood products.