Renal and Urinary Disorders

Kidney function
The Nephron produces Impaired urine production
urine to eliminate waste and azotemia
Secretes Erythropoietin ANEMIA
to increase RBC
Metabolism of Vitamin D Calcium and Phosphate
imbalances
Produces bicarbonate Metabolic ACIDOSIS
and secretes acids
Excretes excess HYPERKALEMIA
POTASSIUM
Urological Assessment
• Nursing History
▫ Reason for seeking care
▫ Current illness
▫ Previous illness
▫ Family History
▫ Social History
▫ Sexual history
Urological Assessment
Key Signs and Symptoms of
Urological Problems
EDEMA
associated with fluid retention
Renal dysfunctions usually
produce ANASARCA
Urological Assessment
Key Signs and Symptoms of
Urological Problems
PAIN
 Suprapubic pain= bladder
Colicky pain on the flank= kidney
Urological Assessment
Key Signs and Symptoms of
Urological Problems
HEMATURIA
Painless hematuria may indicate
URINARY CANCER!
Early-stream hematuria= urethral
lesion
Late-stream hematuria= bladder
lesion
Urological Assessment
Key Signs and Symptoms of
Urological Problems
DYSURIA
Pain with urination= lower UTI
Urological Assessment
Key Signs and Symptoms of
Urological Problems
POLYURIA
More than 2 Liters urine per day
OLIGURIA
Less than 400 mL per day
ANURIA
Less than 50 mL per day
Urological Assessment
Key Signs and Symptoms of Urological
Problems
Urinary Urgency - is a sudden, compelling urge
to urinate
Urinary retention - also known as ischuria is a
lack of ability to urinate
Urinary frequency - Urinating too often, at too
frequent intervals, not due to an unusually large
volume of urine, but rather to a decrease in the
capacity of the bladder to hold urine.
Urological Assessment
PHYSICAL EXAMINATION
Inspection
Auscultation
Percussion
Palpation
Urological Assessment
Laboratory examination
1. Urinalysis
2. BUN and Creatinine levels of
the serum
3. Serum electrolytes
Urological Assessment
Laboratory examination
Radiographic
▫ IVP
▫ KUB x-ray
▫ KUB ultrasound
▫ CT and MRI
▫ Cystography
Implementation Steps for selected
problems
Provide PAIN relief
• Assess the level of pain
• Administer medications usually narcotic
ANALGESICS
Implementation Steps for selected
problems
Maintain Fluid and Electrolyte Balance
• Encourage to consume at least 2 liters of
fluid per day
• In cases of ARF, limit fluid as directed
• Weigh client daily to detect fluid
retention
Implementation Steps for selected
problems
Ensure Adequate urinary elimination
• Encourage to void at least every 2-3 hours
• Promote measures to relieve urinary
retention:
▫ Alternating warm and cold compress
▫ Bedpan
▫ Open faucet
▫ Provide privacy
▫ Catheterization if indicated
• STANDARDS OF CARE GUIDELINES
• Patients at risk for renal impairment include
those with cardiovascular disease, diabetes, and
hypertension; postoperative patients;
hypotensive patients; and those with prostate
and other diseases of the urinary tract.
Thorough assessment of the urinary tract includes:
• Hourly intake and output measurement
• Assessment of color, clarity, and specific gravity
of the urine
• Palpation of the abdomen for suprapubic
tenderness
• Percussion of the flanks for costovertebral angle
tenderness
• Prostate examination
• Subjective assessment for symptoms, such as
urgency, frequency, nocturia, hesitancy,
dribbling, decreased force of stream, hematuria,
and incontinence
• Be alert to drugs that may impair urinary and
renal function, such as nonsteroidal anti-
inflammatory drugs, anticholinergics,
sympathomimetics, aminoglycoside antibiotics.
• Changes in Micturition (Voiding)
Changes in Amount or Color of Urine
• Hematuria - blood in the urine.
▫ Considered a serious sign and requires evaluation.
▫ Color of bloody urine depends on several factors including the
amount of blood present and the anatomical source of the
bleeding.
 Dark, rusty urine indicates bleeding from the upper urinary
tract.
Bright red bloody urine indicates lower urinary tract bleeding.
▫ Hematuria may be due to a systemic cause, such as blood
dyscrasias, anticoagulant therapy, or extreme exercise.
▫ Painless hematuria may indicate neoplasm in the urinary tract.
▫ Hematuria is common in patients with urinary tract stone disease
and may also be seen in renal tuberculosis, polycystic disease of
kidneys, acute pyelonephritis, thrombosis and embolism
involving renal artery or vein, and trauma to the kidneys or
urinary tract.
Polyuria - large volume of urine voided in given
time.
• Volume is out of proportion to usual voiding
pattern and fluid intake.
• Demonstrated in diabetes mellitus, diabetes
insipidus, chronic renal disease, use of diuretics.
Oliguria - small volume of urine.
• Output between 100 and 500 mL/24 hours.
• May result from acute renal failure, shock,
dehydration, fluid and electrolyte imbalance
Anuria - absence of urine output.
• Output less than 50 mL/24 hours.
• Indicates serious renal dysfunction requiring
immediate medical intervention.
Symptoms Related to Irritation of the
Lower Urinary Tract
Dysuria - pain or difficult urination.
• Burning sensation seen in wide variety of
inflammatory and infectious urinary tract
conditions.
Frequency - voiding occurs more commonly
than usual when compared with the patient's
usual pattern or with a generally accepted norm
of once every 3 to 6 hours.

• Increasing frequency can result from a variety of

conditions, such as infection and diseases of
urinary tract, metabolic disease, hypertension,
medications (diuretics).
Urgency - strong desire to urinate that is difficult
to postpone.
• Due to inflammatory conditions of the bladder,
prostate, or urethra; acute or chronic bacterial
infections; neurogenic voiding dysfunctions;
chronic prostatitis or bladder outlet obstruction
in men; and urogenital atrophy in
postmenopausal women.
Nocturia - excessive urination at night, which
interrupts sleep.
• Causes include urologic conditions affecting
bladder function, poor bladder emptying,
bladder outlet obstruction, or overactive
bladder.
• Metabolic causes include decreased renal
concentrating ability or heart failure, diabetes
mellitus, and the increased urine production at
rest that occurs with aging.
Strangury - slow and painful urination; only
small amounts of urine voided.
• Blood staining may be noted.
• Seen in severe cystitis and interstitial cystitis.
Symptoms Related to Obstruction of
the Lower Urinary Tract
• Weak stream - decreased force of stream when
compared to usual stream of urine when voiding.
• Hesitancy - undue delay and difficulty in
initiating voiding.
May indicate compression of urethra, outlet
obstruction, neurogenic bladder.
• Terminal dribbling - prolonged dribbling or
urine from the meatus after urination is
complete. May be caused by bladder outlet
obstruction.

• Incomplete emptying - feeling that the

bladder is still full even after urination. Indicates
either urinary retention or a condition that
prevents the bladder from emptying well; leads
to infection.
Involuntary Voiding
• Urinary incontinence - involuntary loss of
urine; may be due to pathologic, anatomical, or
physiologic factors affecting the urinary tract

• Enuresis - involuntary voiding during sleep.

May be physiologic during early childhood;
thereafter, may be functional or symptomatic of
obstructive or neurogenic disease (usually of
lower urinary tract) or dysfunctional voiding.
Urinary Tract Pain
• Genitourinary (GU) pain is not always present in
renal disease, but is generally seen in the more
acute conditions of the urinary tract.
• Kidney pain - may be felt as a dull ache in
costovertebral angle; or may be a sharp, colicky
pain felt in the flank area that radiates to the
groin or testicle. Due to distention of the renal
capsule; severity related to how quickly it
develops.
• Ureteral pain - felt in the back and radiates to
the groin or scrotum if the upper ureter is the
source, to the suprapubic area, penis, and
urethra if the lower ureter is the source.

• Bladder pain (lower abdominal pain or pain

over suprapubic area) - may be due to bladder
infection or overdistended bladder.
• Urethral pain - from irritation of bladder neck,
from foreign body in canal, or from urethritis
due to infection or trauma; pain increases when
voiding.

• Pain in scrotal area - due to inflammatory

swelling of epididymis or testicle, or torsion of
the testicle.

• Testicular pain - due to injury, mumps,

orchitis, torsion of spermatic cord.
• Perineal or rectal discomfort - due to acute
prostatitis, prostatic abscess.

• Back and leg pain - due to cancer of prostate

with metastases to bone.

• Pain in glans penis is usually from prostatitis;

penile shaft pain is from urethral problems.
History

• What are the patient's present and past

occupations? Look for occupational hazards related
to the urinary tract, contact with chemicals, plastics,
tar, rubber; also truck or school bus drivers.

• What is the past medical and surgical history,

especially in relation to urinary problems?

• Is there any family history of renal disease?

What childhood diseases did the patient have?
• Is there a history of urinary tract infections
(UTIs)? Did any occur before age 12?
• Did enuresis continue beyond the age when
most children gain control?
• Any history of genital lesions or sexually
transmitted diseases (STDs)?
• For the female patient: Number of children?
Vaginal or cesarean delivery? Any forceps
deliveries? When? Any signs of vaginal
discharge? Vaginal/vulvar itch or irritation?
Family history of pelvic organ prolapse (dropped
bladder or uterus) or urinary incontinence?
DIAGNOSTIC TESTS/LABORATORY STUDIES
Tests of Renal Function
• Renal function tests are used to determine
effectiveness of the kidneys' excretory
functioning, to evaluate the severity of kidney
disease, and to follow the patient's progress.
• There is no single test of renal function; best
results are obtained by combining a number of
clinical tests.
• Renal function is variable from time to time.
Nursing and Patient Care Considerations
• Renal function may be within normal limits until
about 50% of renal function has been lost.
Renal concentration test
• Specific gravity
• Osmolality of urine

Purpose/Rationale
• Tests the ability to concentrate solutes in the
urine.
• Concentration ability is lost early in kidney
disease; hence, this test detects early defects in
renal function
Creatinine clearance
• Provides a reasonable approximation of rate of
glomerular filtration.
• Measures volume of blood cleared of creatinine
in 1 minute.
• Most sensitive indication of early renal disease.
• Useful to follow progress of the patient's renal
status.
Serum creatinine
• A test of renal function reflecting the balance
between production and filtration by renal
glomerulus.
• Most sensitive test of renal function.
Serum urea nitrogen (Blood urea nitrogen
[BUN])
• Serves as index of renal excretory capacity.
• Serum urea nitrogen depends on the body's urea
production and on urine flow. (Urea is the
nitrogenous end-product of protein metabolism.)
• Affected by protein intake, tissue breakdown.
Protein
• Random specimen may be affected by dietary
protein intake. Proteinuria >150 mg/24 hours
may indicate renal disease.
Microalbumin/Creatinine ratio
• Sensitive test for the subsequent development of
proteinuria; >30 mcg/mg creatinine predicts
early nephropathy.
Urine casts
• Mucoproteins and other substances present in
renal inflammation; help to identify type of renal
disease (eg, red cell casts present in
glomerulonephritis, fatty casts in nephrotic
syndrome, white cell casts in pyelonephritis).
Prostate-Specific Antigen
• PSA is an amino acid glycoprotein that is measured in
the serum by a simple blood test.
• An elevated PSA indicates the presence of prostate
disease, but is not exclusive to prostate cancer.
• Level rises continuously with the growth of prostate
cancer.
• Normal serum PSA level is less than 4 mg/mL. Levels
less than 10 mg/mL may be indicative of benign
prostatic hyperplasia (BPH) and not necessarily prostate
cancer.
• Patients who have undergone treatment for prostate
cancer are monitored periodically with PSA levels for
recurrence.
PSA
Nursing and Patient Care Considerations
• No patient preparation is necessary.
• Some clinicians prefer not to perform digital
rectal examinations of the prostate at the same
time that a PSA is drawn, to prevent artificial
elevation of PSA level, although this association
has not been proved.
Urinalysis
• Involves examination of the urine for overall
characteristics, including appearance, pH,
specific gravity, and osmolality as well as
microscopic evaluation for the presence of
normal and abnormal cells.
• Appearance - normal urine is clear.
• Cloudy urine (phosphaturia) is not always
pathologic, related only to the precipitation of
phosphates in alkaline urine. Normal urine may
also develop cloudiness on refrigeration or from
standing at room temperature.
• Abnormally cloudy urine due to pus (pyuria),
blood, epithelial cells, bacteria, fat, colloidal
particles, phosphate, or lymph fluid (chyluria).
• Odor - normal urine has a faint aromatic
odor.
• Characteristic odors produced by ingestion of
asparagus, thymol.
• Cloudy urine with ammonia odor - urea-splitting
bacteria such as Proteus, causing UTIs.
• Offensive odor may be due to bacterial action in
presence of pus.
Color shows degree of concentration and depends on amount
voided.
• Normal urine is clear yellow or amber because of the
pigment urochrome.
• Dilute urine is straw-colored.
• Concentrated urine is highly colored; a sign of insufficient
fluid intake.
• Cloudy or smoky colored may be from hematuria,
spermatozoa, prostatic fluid, fat droplets, chyle.
• Red or red-brown due to blood pigments, porphyria,
transfusion reaction, bleeding lesions in urogenital tract,
some drugs and food (beets).
• Yellow-brown or green-brown may reveal obstructive lesion
of bile duct system or obstructive jaundice.
• Dark brown or black due to malignant melanoma, leukemia.
• pH of urine reflects the ability of kidney to maintain
normal hydrogen ion concentration in plasma and
extracellular fluid; indicates acidity or alkalinity of
urine.
• pH should be measured in fresh urine because the
breakdown of urine to ammonia causes urine to
become alkaline.
• Normal pH is around 6 (acid); may normally vary
from 4.6 to 7.5.
• Urine acidity or alkalinity has relatively little clinical
significance unless the patient is on a special diet or
therapeutic program or is being treated for renal
calculous disease.
• Specific gravity reflects the kidney's ability to
concentrate or dilute urine; may reflect degree of
hydration or dehydration.

• Normal specific gravity ranges from 1.005 to

1.025.

• In a person eating a normal diet, inability to

concentrate or dilute urine indicates disease.
• Osmolality is an indication of the amount of
osmotically active particles in urine (number of
particles per unit volume of water). It is similar
to specific gravity, but is considered a more
precise test; it is also easy, only 1 to 2 mL of
urine are required. Average value is 300 to
1,090 mOsm/ kg for females; 390 to 1,090
mOsm/kg for males.
Nursing and Patient Care Considerations
• Freshly voided urine provides the best results for
routine urinalysis; some tests may require first
morning specimen.
• Obtain sample of about 30 mL.
• Urine culture and sensitivity tests are typically
performed using the same specimen obtained for
urinalysis; therefore, use clean-catch or
catheterization techniques.
X-ray of Kidneys, Ureters, and Bladder
• Consists of plain film of the abdomen
• Delineates size, shape, and position of kidneys
• Reveals deviations, such as calcifications
(stones), hydronephrosis, cysts, tumors, or
kidney displacement
Nursing and Patient Care Considerations
• No preparation is needed.
• Usually done before other testing.
• Patient will be asked to wear a gown and remove
all metal from the X-ray field.
Intravenous Pyelogram (Intravenous
Urogram)
• I.V. introduction of a radiopaque contrast
medium that concentrates in the urine and thus
facilitates visualization of the kidneys, ureter,
and bladder.
• The contrast medium is cleared from the
bloodstream by renal excretion.
IVP
IVP
Nursing and Patient Care Considerations
• Contraindicated in patients with renal failure,
uncontrolled diabetes, or multiple myeloma, in patients
receiving drug therapy for chronic bronchitis,
emphysema, or asthma and in patients taking metformin
(Glucophage).
• Patients with known iodine/contrast material allergy
must have steroid/antihistamine preparation; in some
cases, an anesthesiologist must be available.
• Bowel preparation is necessary:
▫ Clear liquids only the day before the examination.
▫ Cathartics/laxatives are given the evening before the
examination.
▫ Nothing by mouth (NPO) after midnight the day of the
examination (if scheduled for afternoon, clear liquids only in the
morning).
Retrograde Pyelography
• Injection of opaque material through ureteral
catheters, which have been passed up ureters
into renal pelvis by means of cystoscopic
manipulation. The opaque solution is introduced
by gravity or syringe injection.
• May be done when intravenous pyelography
(IVP) is contraindicated or if IVP provides
inadequate visualization of the collecting system.
RETROGRADE PYELOGRAPHY
Nursing and Patient Care Considerations
• Contraindicated in patients with UTI, or with
suspected perforation of the ureter or bladder;
allergic reactions to contrast material are rare in
this examination.
Cystourethrogram
• Visualization of urethra and bladder by X-ray
after retrograde instillation of contrast material
through a catheter.
• An examination of only the bladder is a
cystogram; of only the urethra is a urethrogram.
• Used to identify injuries, tumors, or structural
abnormalities of the urethra or bladder; or to
evaluate emptying problems or incontinence
(voiding cystourethrogram).
VOIDING CYSTOURETHROGRAM
Nursing and Patient Care Considerations
• Carries risk of infection due to instrumentation.
• Allergy to contrast material is not a
contraindication.
• Additional X-rays may be taken after catheter is
removed and patient voids (voiding
cystourethrogram).
• Provide reassurance to allay patient's
embarrassment.
Renal Angiography
• I.V. catheter is threaded through the femoral and
iliac arteries into the aorta or renal artery.
• Contrast material is injected to visualize the
renal arterial supply.
• Evaluates blood flow dynamics, demonstrates
abnormal vasculature, and differentiates renal
cysts from renal tumors.
RENAL ANGIOGRAPHY
Nursing and Patient Care Considerations
• Clear liquids only after midnight before the
examination; adequate hydration is essential.
• Continue oral medications (special orders needed
for diabetic patients).
• I.V. required.
• May not be done on the same day as other studies
requiring barium or contrast material.
• Maintain bed rest for 8 hours after the
examination, with the leg kept straight on the
side used for groin access.
• Observe frequently for hematoma or bleeding at
access site. Keep sandbag at bedside for use if
bleeding occurs.
Renal Scans
• Radiopharmaceuticals (also called radiotracers
or isotopes) are injected I.V.
• Evaluates renal size, shape, position, and
function or blood flow to the kidneys.
• Studies are obtained with a scintillation camera
placed posterior to the kidney with the patient in
a supine, prone, or sitting position.
Nursing and Patient Care Considerations
• The patient should be well hydrated. Give
several glasses of water or I.V. fluids as ordered
before scan.
• Furosemide (Lasix) or captopril (Capoten) may
be administered in conjunction with the scan to
determine their effects.
Ultrasound
• Uses high-frequency sound waves passed into the
body and reflected back in varying frequencies
based on the composition of soft tissues. Organs in
the urinary system create characteristic ultrasonic
images that are electronically processed and
displayed as an image.
• Abnormalities, such as masses, malformations, or
obstructions, can be identified; useful in
differentiating between solid and fluid-filled
masses.
• A noninvasive technique.
Cystoscopy
• Cystoscopy is a method of direct visualization of the
urethra and bladder by means of a cystoscope that is
inserted through the urethra into the bladder. It has a
self-contained optical lens system that provides a
magnified, illuminated view of the bladder.
• Uses include:
▫ To inspect bladder wall directly for tumor, stone, or ulcer and to
inspect urethra for abnormalities or to assess degree of prostatic
obstruction.
▫ To allow insertion of ureteral catheters for radiographic studies,
or before abdominal or GU surgery.
▫ To see configuration and position of ureteral orifices.
▫ To remove calculi from urethra, bladder, and ureter.
▫ To diagnose and treat lesions of bladder, urethra, and prostate.
Nursing and Patient Care Considerations
• Simple cystoscopy is usually performed in an office
setting. More complicated cystoscopy involving
resections or ureteral catheter insertions are done in the
operating room cystoscopy suite, where I.V. sedation or
general anesthesia may be used.
• The patient's genitalia are cleaned with an antiseptic
solution just before the examination. A local topical
anesthetic (Xylocaine gel) is instilled into the urethra
before insertion of cystoscope.
• Because fluid flows continuously through the cystoscope,
the patient may feel an urge to urinate during the
examination.
• Contraindicated in patients with known UTI.
Nursing interventions after cystoscopic examination:
• Monitor for complications: urinary retention, urinary
tract hemorrhage, infection within prostate or bladder.
• Expect the patient to have some burning on voiding,
blood-tinged urine, and urinary frequency from trauma
to mucous membrane of the urethra.
• Administer or teach self-administration of antibiotics
prophylactically as ordered to prevent UTI.
• Advise warm sitz baths or analgesics, such as ibuprofen
or acetaminophen, to relieve discomfort after cystoscopy.
Increase hydration.
• Provide routine catheter care if urine retention persists
and an indwelling catheter is ordered.
Urodynamics
• Urodynamics is a term that refers to any of the
following tests that provide physiologic and
functional information about the lower urinary
tract. They measure the ability of the bladder to
store and empty urine. Most urodynamic
equipment uses computer technology with
results visible in real time on a monitor.
1. Uroflowmetry (flow rate) - a record of the
volume of urine passing through the urethra per
unit of time (mL/s). It is shown on graph paper
and gives information about the rate and flow
pattern of urination.

2. Cystometrogram - recording of the pressures

exerted during filling and emptying of the urinary
bladder to assess its function. Data about the
ability of the bladder to store urine at low pressure
and the ability of the bladder to contract
appropriately to empty urine are obtained.
3. Sphincter electromyelography (EMG)
measures the activity of the pelvic floor muscles
during bladder filling and emptying. EMG
activity may be measured using surface (patch)
electrodes placed around the anus or with
percutaneous wire or needle electrodes.

4. Pressure-flow studies involve all of the

above components, along with the simultaneous
measurement of intra-abdominal pressure by
way of a small tube with a fluid-filled balloon
that is placed in the rectum. This permits better
interpretation of actual bladder pressures
without the influence of intra-abdominal
pressure.
5. Video urodynamics use all of the above
components. The fluid used to fill the bladder is
contrast material, and the entire study is
performed under fluoroscopy, providing
radiographic pictures in combination with the
recording of bladder and intra-abdominal
pressures. Video urodynamics are reserved for
patients with complicated voiding dysfunction.
Nursing and Patient Care Considerations
• Contraindicated in patients with UTI.
• Frequently performed by nurses; essential to
provide information and support throughout the
test to ensure clinically significant results.
• Patients will have burning on urination afterward
(due to instrumentation); encourage fluids.
• Short-term antibiotics are commonly given to
prevent infection
Needle Biopsy of Kidney
• Performed by percutaneous needle biopsy
through renal tissue with ultrasound guidance or
by open biopsy through a small flank incision;
useful in securing specimens for electron and
immunofluorescent microscopy to determine
diagnosis, treatment, and prognosis of renal
disease
• Nursing and Patient Care Considerations
• Prebiopsy nursing management
▫ Ensure that coagulation studies are carried out to
identify the patient at risk for postbiopsy bleeding and
that serum creatinine, urinalysis, and urine culture are
done.
▫ Ensure that patient fasts for several hours before the
procedure, as ordered.
▫ Establish an I.V. line, as ordered.
▫ Describe the procedure to the patient, including
holding breath (to prevent movement of the thorax)
during insertion of the biopsy needle.
Instruct the patient on the following after biopsy:
• Avoid strenuous activity, strenuous sports, and
heavy lifting for at least 2 weeks.
• Notify health care provider if any of the
following occur: flank pain, hematuria,
lightheadedness and fainting, rapid pulse, or any
other signs and symptoms of bleeding.
• Report for follow-up 1 to 2 months after biopsy;
will be checked for hypertension, and the biopsy
area is auscultated for a bruit.
CATHETERIZATION
• Catheterization may be done to relieve acute or
chronic urinary retention, to drain urine
preoperatively and postoperatively, to determine
the amount of residual urine after voiding, or to
determine accurate measurement of urinary
drainage in critically ill patients.
DIALYSIS
• Dialysis refers to the diffusion of solute
molecules through a semipermeable membrane,
passing from the side of higher concentration to
that of lower concentration.
• The purpose of dialysis is to maintain the life
and well-being of the patient.
• It is a substitute for some kidney excretory
functions but does not replace the kidneys'
endocrine and metabolic functions.
Methods of dialysis include:
• Peritoneal dialysis.
▫ Intermittent peritoneal dialysis (acute or chronic)
▫ Continuous ambulatory peritoneal dialysis.
▫ Continuous cycling peritoneal dialysis uses
automated peritoneal dialysis machine overnight
with prolonged dwell time during day.
Hemodialysis Hemodialysis
• Hemodialysis is a process of cleansing the blood
of accumulated waste products. It is used for
patients with end-stage renal failure or for
acutely ill patients who require short-term
dialysis.
Methods of Circulatory Access
• Arteriovenous fistula (AVF) - creation of a
vascular communication by suturing a vein
directly to an artery
AV fistula
• Arteriovenous graft - arteriovenous connection
consisting of a tube graft made from autologous
saphenous vein or from polytetrafluoroethylene.
Ready to use in 2 to 3 weeks.
• Central vein catheters - direct cannulation of
veins (subclavian, internal jugular, or femoral);
may be used as temporary or permanent dialysis
access.
Central venous catheter
Complications of Vascular Access
• Infection
• Catheter clotting
• Central vein thrombosis or stricture
• Stenosis or thrombosis
• Ischemia of the hand (steal syndrome)
• Aneurysm or pseudoaneurysm
Lifestyle Management for Chronic Hemodialysis
• Dietary management involves restriction or
adjustment of protein, sodium, potassium, or
fluid intake.
• Ongoing health care monitoring includes careful
adjustment of medications that are normally
excreted by the kidney or are dialyzable.
• Surveillance for complications.
▫ Arteriosclerotic cardiovascular disease, heart failure,
disturbance of lipid metabolism (hypertriglyceridemia),
coronary heart disease, stroke
▫ Anemia and fatigue
▫ Gastric ulcers and other problems
▫ Bone problems (renal osteodystrophy, aseptic necrosis
of hip) from disturbed calcium metabolism
▫ Hypertension
▫ Psychosocial problems: depression, suicide, sexual
dysfunction
Continuous Ambulatory Peritoneal Dialysis
• Continuous ambulatory peritoneal dialysis (CAPD) is a
form of intracorporeal dialysis that uses the peritoneum
for the semipermeable membrane
Advantages Over Hemodialysis
• Physical and psychological freedom and
independence
• More liberal diet and fluid intake
• Relatively simple and easy to use
• Satisfactory biochemical control of uremia
Complications
• Infectious peritonitis, exit-site and tunnel
infections.
• Noninfectious catheter malfunction, obstruction,
dialysis-sate leak.
• Peritoneal pleural communication, hernia
formation.
• GI bloating, distention, nausea.
• Hypervolemia, hypovolemia.
• Bleeding at catheter site..
• Obstruction may occur if omentum becomes
wrapped around the catheter or the catheter
becomes caught in a loop of bowel.
LOWER URINARY TRACT INFECTIONS
• A UTI is caused by the presence of pathogenic
microorganisms in the urinary tract with or
without signs and symptoms. Lower UTIs may
predominate at the bladder (cystitis) or urethra
(urethritis).
Urinary Tract Infection (UTI)

•Bacterial invasion of
the kidneys or bladder
(CYSTITIS) usually
caused by Escherichia
coli
Urinary Tract Infection (UTI)
• Predisposing factors include
1. Poor hygiene
2. Irritation from bubble baths
3. Urinary reflux
4. Instrumentation
5. Residual urine, urinary stasis
Urinary Tract Infection (UTI)

PATHOPHYSIOLOGY
• The invading organism ascends the
urinary tract, irritating the mucosa and
causing characteristic symptoms
▫ Ureter= ureteritis
▫ Bladder= cystitis
▫ Urethra=Urethritis
▫ Pelvis= Pyelonephritis
• Women are more susceptible to developing acute
cystitis because of shorter length of urethra,
anatomical proximity to vagina, periurethral
glands, and rectum (fecal contamination), and
the mechanical effect of coitus.
• Poor voiding habits may result in incomplete
bladder emptying, increasing the risk of
recurrent infection.
• Acute infection in women most commonly arises
from organisms of the patient's own intestinal
flora (Escherichia coli).
In men, obstructive abnormalities (strictures,
prostatic hyperplasia) are the most frequent
cause.
Assessment findings
Urinary Tract Infection (UTI)
Urinary Tract Infection (UTI)
Assessment findings
• Low-grade fever
• Abdominal pain
• Enuresis
• Pain/burning on urination
• Urinary frequency
• Hematuria
Urinary Tract Infection (UTI)
Assessment findings: Upper UTI
• Fever and CHIILS
• Flank pain
• Costovertebral angle
tenderness
Urinary Tract Infection (UTI)
Laboratory Examination
1. Urinalysis
2. Urine Culture
Urinary Tract Infection (UTI)
Nursing interventions
• Administer antibiotics as ordered
• Provide warm baths and allow client to
void in water to alleviate painful voiding.
• Force fluids. Nurses may give 3 liters of
fluid per day
• Encourage measures to acidify urine
(cranberry juice, acid-ash diet).
Urinary Tract Infection (UTI)
• Provide client teaching and discharge
planning concerning
a. Avoidance of tub baths
b. Avoidance of bubble baths that might
irritate urethra
c. Importance for girls to wipe perineum
from front to back
d. Increase in foods/fluids that acidify
urine.
Urinary Tract Infection (UTI)
Pharmacology
1. Sulfa drugs
▫ Highly concentrated in the urine
▫ Effective against E. coli!

2. Quinolones
• Bacteriuria refers to the presence of bacteria in
the urine (105 bacteria/mL of urine or greater
generally indicates infection).
• In asymptomatic bacteriuria, organisms are
found in urine, but the patient has no symptoms.
Recurrent UTIs may indicate the following:
• Relapse - recurrent infection with an organism
that has been isolated during a prior infection
• Reinfection - recurrent infection with an
organism distinct from previous infecting
organism
Complications
• Pyelonephritis
• Hematogenous spread resulting in sepsis
Nursing Diagnoses
• Acute Pain related to inflammation of the
bladder mucosa
• Deficient Knowledge related to prevention of
recurrent UTI
THE END