Learning Plan 6 Renal Urinary Alterations Fluid & Electrolyte (Kidney disorders)

Kidney and Urinary Systems Regulates fluid and electrolytes, removing wastes and providing hormones involved in red blood cell production, bone metabolism, and control of blood pressure Structures Kidneys Ureters Bladder Urethra

Structure & Functions of the Kidney Urine formation Excretion of waste products Regulation of electrolytes Regulation of acid–base balance Control of water balance Control of blood pressure Renal clearance Regulation of red blood cell production Synthesis of vitamin D to active form Secretion of prostaglandins Regulates calcium and phosphorus balance

Formation of Urine Nephron GFR < 60ml/min: mild to moderate loss function

Renin Angiotensin System

Gerontologic Considerations Older adults may intentionally limit fluids to decrease frequency or incontinence Diminished thirst, need reminding to drink, increased dehydration Incomplete emptying of bladder, urinary stasis, decreased nerve innervations Decreased GFR and renal reserve Decreased drug clearance = increased drug–drug interactions

Cystoscopic Examination Diagnostic Studies Urinalysis and urine culture Renal function tests: refer to Table 53-5 Ultrasonography CT and MRI Nuclear scans IV urography Retrograde pyelography Renal angiography Cystography Endoscopic procedures Biopsies Cystoscopic Examination

Question Is the following statement true or false? Urea is an abnormal constituent of urine.

Nursing Process: The Care of the Patient Undergoing Testing of the Renal–Urologic System—Assessment Patient knowledge Psychosocial and emotional factors; fear, anxiety Urologic function, include voiding habits/pattern Fluid intake Hygiene Presence of pain or discomfort Allergies

What is the normal adult bladder capacity? Question What is the normal adult bladder capacity? 50 to 100 mL 100 to 200 mL 300 to 500 mL 600 to 800 mL

Nursing Process: The Care of the Patient Undergoing Testing of the Renal–Urologic System—Diagnosis Knowledge deficient Pain Fear Refer to Chart 53-4

Nursing Process: The Care of the Patient Undergoing Testing of the Renal–Urologic System—Interventions Encourage fluid intake unless contraindicated Instruct in methods to reduce discomfort; sitz baths, relaxation techniques Administer analgesics and antispasmodics as prescribed Assess voiding and provide instruction related to voiding practices and hygiene Provide privacy and respect Refer to Chart 53-4

Question A 24-hour urine collection is scheduled to start at 0100. When should the nurse start the procedure? At 0100, with or without a specimen At the first specimen that was voided at 0400 2 hours after the urine was discarded After discarding the 0100 specimen

Fluid & electrolyte (AKI, ESRD, & dialysis)

Kidney Disorders Fluid and electrolyte imbalances Most accurate indicator of fluid loss or gain, in an acutely ill patient, is weight Refer to Table 54-1

Question Is the following statement true or false? The most accurate indicator of fluid loss or gain in an acutely ill patient is weight.

Causes of Acute Kidney Failure Causes of Chronic Kidney Failure Diabetes mellitus Hypertension Chronic glomerulonephritis, Pyelonephritis or other infections Obstruction of urinary tract Hereditary lesions Vascular disorders Medications or toxic agents Hypovolemia Hypotension Reduced cardiac output and heart failure Obstruction of the kidney or lower urinary tract Obstruction of renal arteries or veins

Acute Kidney Injury Prerenal: Severe dehydration, ↓ CO Intrarenal: Oliguria Autoregulatory mechanisms Intrarenal: Acute Tubular Necrosis; nephrotoxins, ischemia Post renal: BPH, calculi, trauma, tumors

Glomerular Diseases Inflammation of the glomerular capillaries Acute nephritic syndrome Chronic glomerulonephritis Nephrotic syndrome

Acute Nephritic Syndrome Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, and membranous glomerulonephritis Manifestations include hematuria, edema, azotemia, proteinuria, and hypertension May be mild or may progress to acute renal failure or death Medical management includes supportive care and dietary modifications; treat cause if appropriate—antibiotics, corticosteroids, and immunosuppressants

Nursing Management: Acute Nephritic Syndrome Patient assessment Maintain fluid balance Fluid and dietary restrictions Patient education Follow-up care

Chronic Glomerulonephritis Repeated acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage Renal insufficiency or failure: asymptomatic for years as glomerular damage increases before signs and symptoms develop Abnormal laboratory test results: urine with fixed specific gravity, casts, proteinuria, electrolyte imbalances and hypoalbuminemia Medical management determined by symptoms

Nursing Process Assessment Potential fluid and electrolyte imbalances Cardiac status Neurologic status Emotional support Education in self-care

Sequence of Nephrotic Syndrome Any condition that seriously damages the glomerular membrane and results in increased permeability to plasma proteins Results in hypoalbuminemia and edema Causes include chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis, amyloidosis, lupus erythematosus, multiple myeloma, and renal vein thrombosis Medical management includes drug and dietary therapy Sequence of Nephrotic Syndrome

Kidney Failure Results when the kidneys cannot remove wastes or perform regulatory functions A systemic disorder that results from many different causes Acute renal failure is a reversible syndrome that results in decreased glomerular filtration rate and oliguria Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia Acute and Chronic Kidney Injury Assessment: Fluid status Nutritional status Patient knowledge Activity tolerance Self-esteem Potential complications

Collaborative Problems and Complications Nursing Process: The Care of Patients With Chronic Kidney Disease and Acute Kidney Injury—Diagnosis Excess fluid volume Imbalanced nutrition Deficient knowledge Risk for situational low self-esteem Collaborative Problems and Complications Hyperkalemia Pericarditis Pericardial effusion Pericardial tamponade Hypertension Anemia Bone disease and metastatic calcifications

Imbalanced Nutrition: Assessment Excess Fluid Volume Imbalanced Nutrition: Assessment Assess for s/s of fluid volume excess, keep accurate I&O, and daily weights Limit fluid to prescribe amounts Identify sources of fluid Explain to patient and family the rationale for fluid restrictions Assist patient to cope with the fluid restrictions Provide or encourage frequent oral hygiene Nutritional status; weight changes, laboratory data Nutritional patterns, history, preferences Provide food preferences within restrictions Encourage high-quality nutritional foods while maintaining nutritional restrictions Stomatitis or anorexia: modify intake related to factors that contribute to alterations Adjust medication times related to meals

Risk for Situational Low Self-Esteem Assess patient and family responses to illness and treatment Assess relationships and coping patterns Encourage open discussion about changes and concerns Explore alternate ways of sexual expression Discuss role of giving and receiving love, warmth, and affection

Stages of Chronic Kidney Disease

Dialysis Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure Treat drug overdoses Begun for ESKD when patient’s uremia can no longer be adequately managed conservatively Initiated when GFR (or creatinine clearance) is less than 15 mL/min Two methods of dialysis available Peritoneal dialysis (PD) Hemodialysis (HD)

Hemodialysis Catheter

Internal Arteriovenous Fistula and Graft Assessment of Fistula/Graft Auscultate bruit Palpate thrill

Medications Hold Prior to HD Laxatives or stool softeners Individuals confined to chairs for 4 hours Vitamins Antihypertensives Antibiotics Digoxin Daily medication doses Dialysis late afternoons: medications administered early morning

Hemodialysis System

Peritoneal Dialysis

Peritoneal Dialysis READ ME Dialysate drainage bag

Peritoneal Dialysis Dialysis solution warmed to: - Encourage removal of urea - Prevent hypothermia - Promote comfort Three phases: Called an exchange Inflow time Dwell time 1 hour 12 hours (CAPD) Drain time Strict ASEPTIC technique with sterile gloves and mask Assess drained solution for signs of infection Weigh pt before and after treatments

Question Is the following statement true or false? Failure of the temporary dialysis access accounts for most hospital admissions of patients undergoing chronic hemodialysis.