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KIDNEYS: − Located between 12th thoracic & 3rd lumbar vertebrae. Each kidney 4-5 inches long. More than 1 million nephrons in each kidney. Urine flows from nephrons in the parenchyma into the renal pelvis, which tunnels it into the ureter − FUNCTIONS: (KIDNEYS) o Filters blood to remove waste products o Regulate fluid and electrolyte o Regulates acid-base balance o Urine formation o Hormone production (growth hormone) o Regulates calcium and phosphorous o Erythropoietin (stimulates RBC production) o Activates Vitamin D (promotes bone reabsorption of calcium & phosphorus) o Renin (assists with blood pressure regulation) o Prostaglandin secretion URETERS: − Connects each kidney to the bladder. Urine is propelled from the kidney to the urinary bladder via peristaltic contractions of the smooth muscle fibers in the middle layer of the ureter. URINARY BLADDER: − Muscular sac that serves as a reservoir for urine. Composed of an inner lining of epithelial cells, a middle layer of three muscle types, and an outer lining. − Holds 300 to 600 ml urine − Bladder fullness sensation at 150 to 200 ml in adults URETHRA: − Provides passageway for urine to be eliminated, leads from urinary bladder to the urethral meatus where urine exits the body: 6-8 inches in males, 1-2 inches in females, this difference in length predisposes women to UTI’s Urine Formation: − 3 Step Process in Nephrons o Glomerular Filtration- Fluid in the blood is filtered across the capillaries of the glomerulus and into the urinary space of the Bowman’s capsule o Tubular Reabsorption- Passage of fluid from Bowman’s capsule to the proximal tubules where reabsorption takes place (body selectively keeps the substances it needs while ridding itself of wastes) o Tubular Secretion- Passage of unwanted substances from capillaries surrounding the nephron are added to the glomerular filtrate
Parts of Nephron: − Antidiuretic Hormone (ADH) o Other name Vasopressin o Hormone secreted by the posterior pituitary o Decreases the production of urine by increasing reabsorption of water by the renal tubules − Atrial Natriuretic Factor (ANF) or Atrial Natriuretic Peptide (ANP) o a hormone released to regulate renal and cardiovascular homeostasis o Release in response to atrial dilation or increased intravascular volume o Causes natriuresis, diuresis, renal vasodilation o Reduces circulating concentrations of renin, aldosterone, and antidiuretic hormone (ADH) Assessment: − Health history − Physical exam − Age-related changes − Health History − Subjective Data − Past health history − Medications − Nutritional status − Activity-rest patterns − Elimination patterns − Sexuality and reproductive pattern − Cognitive and perceptual pattern − Self perception and self concept − Role and relationship patterns Physical Exam: − Objective Data − Inspection (external genitalia, edema) − Palpation- costovertebral angle (CVA) − Percussion bladder (tympanic to dull) − Auscultation (for bruits or thrills) − Age-Related Changes of the Kidney − Decrease in the size & weight − Decrease in the blood flow − Decrease in the number of functioning glomeruli − Decreased glomerular filtration rate (GFR)
3 − − Decrease ability to conserve Na, dilute or concentrate urine & excrete an acid load Decrease renal reserve function
Diagnostic Studies Used to Assess Genitourinary Function: − Urinalysis (needs at least 10 ml) o Random specimens-collected at any time collected in a clean container, cannot be used for urine C&S − Clean-Catch Specimen (midstream urine) o Women- separate labia and cleanse front to back with antiseptic towelette, then void some into commode, then collect specimen in sterile container. o Men- Retract foreskin and cleanse in circular motion from meatus to glans penis, void some in commode, then void in sterile container. This type specimen is done if urine is to be cultured. − Catheterized specimen- may be a catheterized specimen or may be withdrawn from indwelling catheter (must be fresh urine), and almost always used for specimens to be cultured. − 24-Hour specimens (also referred to as “composite urine specimen”)collected in one large container. Some specimens need a chemical preservative in container &/or refrigeration, so check with the lab. o Container may be packed in container of ice or insulated ice packs. When specimen collection begins, patient voids and this specimen is discarded. All urine for next 24 hours is placed in container. o 24 hours from time of first voiding, nurse instructs patient to void and adds this to container and sends to lab. If any voiding is not added, must restart test!! − Renal Clearance o Kidneys ability to clear solutes from plasma o Most popular test is creatinine clearance − Creatinine clearance (urine) is most common 24 hour urine ordered. o Male: 95-135 mL/min o Female: 85-125 mL/min o Calculated By o Volume of urine(mL/min) X Urine creatinine (mL/dL) Serum creatinine (mg/dL) − Normal Findings in Routine Urinalysis o Color- pale yellow to deep amber (some color changes because of medications and certain foods or pathology) o Opacity- clear (increases in opacity denote presence of bacteria, crystals, or other foreign material)
4 o o Specific Gravity- 1.003-1.030 (indicates concentration of urine, usually the more concentrated the urine, the more fluid-depleted the person Osmolality 275-300 mOsm/L up to 900 mOsm/L(measures concentrating ability of kidneys, urine osmolality ^ with hypernatremia, acidosis, & shock, hypercalcemia, renal tubular acidosis and sometimes hyperglycemia) pH- 4.5-8.0 Ketones- negative (found if body’s fat stores are metabolized for energy; diabetes, fasting, etc) Glucose- negative Protein- negative (if found, may indicate abnormal glomerular permeability) Bilirubin- negative (indicates bilary tract obstruction or liver disease) RBC- none-3 (presence may indicate UTI or other pathology of urinary tract, trauma and also seen in hemolytic transfusion reactions) WBC- none-4 (presence indicates infection in urinary tract) Bacteria- none (presence represents infection or contamination of specimen) Casts- none (formed by agglutination of protein, presence usually indicates tubular or glomerular disease) Crystals- none (presence may not indicate disease, but important predisposing factor in calculus formation) Studies BUN- 7-18 mg/dL Blood urea nitrogen (any renal function impairment causes an increase in the plasma urea level) BUN/Creatinine ratio= 10:1 Serum Creatinine:
o o o o o o o o o o − Blood o
Normal= 0.6-1.2 mg/dL (increased serum levels indicate decreased renal function) o Bacteremia- Presence of bacteria in blood. Identified by blood cultures o GFR= 125mL/min to 200mL/min Radiological Studies o KUB- X-ray of kidneys, ureters, bladder( determines size, location, shape, malformation, stones and calcified areas) o Ultasonography-sound waves that detect abn and of tissue) o Computed Tomography (CT)-show cross sections of tissue o Magnetic Resonance Imaging (MRI)- shows cross sections of tissue o No metal objects, sedatives may be needed (Intravenous urography) IVP- intravenous pyelogram- IV contrast medium is injected and X-rays taken at intervals to identify any pathophysiology
5 *Make sure not allergic to shellfish o Cystography - dye injected into bladder via a catheter and bladder is filled, profiles size, shape, and any reflux from bladder into ureters. o Cystogram-radiograph produced by cystography. o Voiding cystourethrography –dye instilled into bladder by catheter. Then person voids while x-raying. Used to assess reflux. o Renal Angiography- dye injected via femoral artery to determine and diagnose renal pathology. Observe for hemorrhaging after procedure, pressure dressing, etc. and frequent checks of neurovascular status in affected extremity. Diagnostic Study o Cystoscopy : direct visualization of the urinary tract with insertion of a cystoscope into the bladder via urethra Diagnostic: *inspect bladder to see tumors, calculi, ulcers, irritation; *collect urine from renal pelvis; *retrograde pyelography; *measuring bladder capacity Post-procedure: pink-tinged urine is common, but bright red bleeding or clots should be reported. Back pain, bladder spasms, fullness and dysuria may occur. Sitz baths, B&O supp. or antispasmodics may be ordered. Observe for urinary retention. o Kidney Biopsy: Can be open or closed. Percutaneous renal biopsy is most frequent (specially designed needle pierces the skin and enters the kidney to obtain small sample of tissue) Pre-procedure: • Consent • H & H and coagulations studies prior • Medicate so no coughing afterwards • Pre-procedure teaching about 4 hours in bed without movement afterwards • Baseline VS • Prone position • May have to fast 6 to 8 hours before • Baseline urine specimen collected Post-prodedure- *Hemorrhage is a major complication, observe for hematuria, flank or abd. Pain, hypotension, heavy ecchymosis or hematoma formation over kidney, observe site frequently, V/S, bedrest X 4 hours (up to 24 hours if high risk for bleed) Avoid straining/coughing, force fluids, collect serial urines, keeping samples of each voiding for comparison and analysis for presence of blood and clearing of RBCs or increase.
6 − Normal Lab Values: o BUN (8- 25mg/dl o Creatinine (0.6- 1.5mg/dl) o Phosphorous (2.8- 4.5mg/dl) o Calcium (9 – 11mg/dl) o Sodium (135- 145mEq/L) o Potassium (3.5- 5.5mEq/L) o Hematocrit (38 – 47% female) (40- 54% male) o Hemoglobin (12- 16g/dl female) (13.5 -18g/dl male)
Terms :Page 1503 − Dysuria − Enuresis − Hematuria − Nocturia − Oliguria − Polyuria − Anuria − Residual urine − Frequency − Urgency − Hesitancy − Incontinence − Proteinuria − Pyuria − Micturition Relapse: − Bacterial Persistence − Sterilization of the urine is short-lived − Within weeks a relapse with the identical organism occurs − Site of persistent infection within the urinary tract that could be a stone or infected anatomic anomaly Nursing care: − Acute Glomerulonephritis o Acute poststreptococcal glomerulonephritis is the result of antigenantibody reaction where insoluble immune complexes develop and become entrapped in glomerular tissue, producing swelling and death of capillary cells. o Also occurs after Impetigo, Acute viral infections o Renal function is impaired by scarring and obstruction of circulating blood flow through the glomerulus
7 o Most common in children and young adults Acute Glomerulonephritis: Clinical Manifestations o Early: Hematuria with smoky or rusty appearance Proteinuria Azotemia Increased urine specific gravity ^ESR (erythrocyte sedimentation rate) Oliguria
Late: Circulatory congestion = CHF & pulmonary edema (in Elderly) Hypertension Edema Kidney failure Possible abd or flank pain H/A Malaise Treatment/Nursing Care Medications: Antibiotics-penicillin if strep present Steriods to reduce inflammation Immunosuppressants Loop diuretics Angiotensin II receptor blocking agents Maybe Kayexalate to treat ^ K+ Treatment/Nursing Care
Sodium, water, protein restrictions Bed rest till B/P normal and edema abates. I&O Daily weights Monitor edema and lung sounds frequently along with VS Patient education Chronic Glomerulonephritis: o Results from acute glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury, glomerular sclerosis o It’s characterized by progressive destruction of glomeruli and gradual loss of renal function. o The glomeruli become sclerosed and the kidney size decreases.
8 o Signs/Symptoms of CGN Proteinuria Hematuria Dyspnea on exertion Blurred vision Weakness/fatigue Edema Nocturia Weight loss H/A Dizziness Digestive disturbances Irritability Yellow-gray pigment to skin Symptoms of heart failure
Symptomatic Similar to that of AGN when hematuria, hypertension, and edema present. Treatment of kidney failure begins when the illness progresses to end-stage renal disease Nursing care as AGN Nephrotic Syndrome (Nephrosis): − Not a single disease entity but a constellation of symptoms: o *Albuminuria o *Hypoalbuminemia o *Edema o *Hyperlipidemia o *Lipuria (fat in urine) − Associated with: o *Allergic reactions (insect bites, pollen) o *Infections (Strep, syphilis) o *Systemic disease (diabetes, lupus, Goodpasture’s syndrome, sickle cell disease) o *Circulatory problems (CHF, Chronic constrictive pericarditis) o *Cancers o *Drugs o *Renal transplantation o *Pregnancy − In adults known glomerular disease is most common precipitating event. − In children the cause is idiopathic. − Initial change is damage to cells in glomerular basement membrane from immune complex deposition, nephrotoxic antibiodies, or other nonimmune mechanisms.
9 The capillary hydrostatic fluid pressure becomes greater than the capillary osmotic pressure = generalized edema. − Changes = increased membrane porosity and permeability with significant proteinuria and decreased serum albumin as protein is excreted in the urine. − S/S: o Anasarca (severe generalized edema) o Periorbital edema o Ascites o H/A o Malaise o Proteinuria o Irritability o Hypoalbuminemia o Hyperlipidemia − Treatment/Nursing Care o Small frequent feedings encourage dietary intake o Frequent mouth care to reduce unpleasant metallic taste and breath o Daily weights and I&O, abd girth o Monitor lab values o Protect from infections o Symptomatic o Cortiocosteroids (severe cases) o Antineoplastics (Cytoxan) severe cases o Immunosuppressants o Anticoagulants (if thrombus detected) o Antihypertensives o Lipid lowering agents (Colestid, Mevacor)-low cholesterol diet o Sodium restricted diet (2 to 3 g/day) b/c of edema o Thiazide or loop diuretics o Low to moderate protein (0.5kg to 0.6kg/day), if loss exceeds 10g per 24 hrs additional protein is needed Urinary Retention: − Urine continues to be produced, but accumulated urine in bladder is not released. Multiple causes, but if uncorrected leads to UTIs, stone formation, and reflux of urine into ureters and into kidneys leading to hydronephorsis. − Inability to empty bladder completely − Under 60 years old bladder should empty completely − Over 60 years old 50 to 100ml of residual urine may remain after voiding − Surgery may cause urinary retention − Medications may cause (Ditropan, B & O suppositories, Bentyl, Tricyclic Antidepressants) −
10 − − − Disease conditions Full bladder can be palpated above symphysis pubis, sometimes displaced to the side and percussion produces tympanic to dull sound. Nursing Measures: o Provide privacy o Run water o Pour warm water over perineum o Sitz bath o Stand or sit to void o Medications o Catheterization o Surgical intervention
Prevention of Infections Foley Catheters: − Maintain closed system − *Aseptic technique if needs irrigation − *Avoid backflow of urine, keep drainage bag below bladder level − *Catheter care Q 8 hours − Avoid unnecessary manipulation of catheter − *Maintain patency of catheter − *Encourage fluid intake − *Provide urine acidification UNINARY TRACT INFECTIONS: − LOWER URINARY TRACT INFECTIONS o Cystitis- infection in bladder o Urethritis- inflammation of the urethra o Prostatitis -inflammation of the prostate − UPPER URINARY TRACT INFECTIONS o Pyelonephritis- infection in renal pelvis o Chronic pyelonephritis o Interstitial nephritis- inflammation of the kidney o Renal abscesses o Urosepsis- sepsis (widespread infection in bloodstream) resulting from UTI o Pyelonephritis Upper Urinary tract infection involving the renal pelvis, tubules, and interstitial tissue of the kidney Types of Pyelonephritis • Acute: caused by infections and abscesses • Chronic: caused by chronic kidney disease Clinical Manifestations Pyelonephritis
11 • Acute o Fever o Chills o Leukocytosis o Bacteriuria o Pyuria o Low back pain o Flank pain o N/V Chronic o Usually no symptoms o Fatigue o H/A o Poor appetite o Polyuria o Excessive thirst o Weight loss
Treatment Pyelonephritis • Acute o Ultrasound/CT o U/A o Antibiotics-(Bactrim, Cipro, Gentamicin, Ampicillin) o Follow-up U/A o Hydration • Chronic o Long term antibiotic use o Monitor renal function studies
Nursing Management Pyelonephritis o Collection of U/A o Monitor intake and output o Encourage 3 to 4 Liters fluid/day o Monitor temp o Teach preventive measures Factors That Increase The Incidence of UTIs o Obstructiono Stricture o Congenital abnormality o Prostatic hypertrophy o Renal stone o Renal cyst o Factors That Increase The Incidence of UTIs
12 o Urinary Instrumentationo Cystoscopy o Prostatectomy o Renal biopsy o Prostatic biopsy o Foreign Bodyo Indwelling catheter o Ureteric stent o Nephrostomy tube o Metabolic disease or illnesso Diabetes o Postrenal transplantation o Urinary diversiono Ileal conduit o Funtional abnormalityo Neurogenic bladder o Vesicoureteral reflux Prevention of UTIs o Wiping from urinary meatus back o *Taking showers instead of baths, or taking baths w/less water in tub o *Avoiding bubble baths o *Wearing cotton underpants o *Cleansing perineum prior and voiding prior to and after intercourse o Not wearing wet bathing suits all day o *Drinking adequate fluids, esp. cranberry o *Voiding at regular intervals o *Unprotected anal intercourse o *Infrequent changing of baby’s diapers Other Risk Factors For UTIs o Tampons & tight clothing o *Diaphragm & spermicides o *Lack of circumcision o Women at higher risk because urethra is shorter & men have zinc in prostatic fluid which acts as antibacterial agent Clinical Manifestations of UTIs o Burning upon urination o *Frequency o *Urgency o *Inability to void o *Voiding in small amounts o *Hematuria
13 o *Abdominal/flank pain o *Malaise, fever, chills Treatment of UTIs o * Increase fluids o *Antibacterial agents for prescribed length of time: o Bactrim common antiinfective
(sulfa family causes crystalluria = force fluids to 8 glasses a day. Avoid excessive sunlight = burns) o Pyridium- urinary anesthetic agent, turns urine red-orange = decreased pain & burning. Renal Tuberculosis: − Primary lesion secondary to TB of the lungs. Lesions ulcerates and infections descends to bladder − Asymptomatic initially − Fatigue, low-grade fever, frequent urination, burning on voiding, epididymitis − Nursing Care
Urethral Syndrome: − Primarily affects women, unknown cause − Irritated bladder − Frequency − Urgency − Hesitancy − Burning − Low back pain − Suprapubic pain − Urethral Syndrome
Dx -cytoscopy -xrays Tx antibiotics nursing care
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