Professional Documents
Culture Documents
GERONTOLOGIC CONSIDERATIONS:
• Older adults may intentionally limit fluids to decrease frequency or incontinence
• Diminished thirst, need reminding to drink, increased dehydration. More prone to developing hypernatremia and fluid
volume deficit.
• Incomplete emptying of bladder, urinary stasis, decreased nerve innervations
• Decreased GFR
• Decreased drug clearance = increased drug–drug interactions
URINE
• SPECIFIC GRAVITY – 1.010 – 1.025, largely depends on hydration status = ↑fluid / ↓SG or ↓fluid / ↑SG
• OSMOLALITY – 250 – 900 mOsm/kg/24h
• STORAGE – bladder fullness sensation at 150-200 ml, functional capacity at 400-500 ml, neurologic changes can cause
abnormal high volumes up to 2,000 ml. Normal storage period is 2 -4 hours during day and 6-8 hr at night. Residual <50 ml
in middle age adults and < 50-100 ml in older adults.
• COLOR
RENAL FUNCTION TESTS
• SPECIFIC GRAVITY – 1.010 – 1.025, largely depends on hydration status = ↑fluid / ↓SG or ↓fluid / ↑SG
• OSMOLALITY – 250 – 900 mOsm/kg/24h
• 24 HR URINE – creatinine clearance, 52 – 146 depending on age and sex (decreases with age, females slightly lower)
• BLOOD SERUM TESTS:
– Creatinine-effectiveness of renal function (0.6-1.2)
– BUN-affected by protein intake, tissue breakdown & fluid volume. (7-18) (patients >60 y = 8-20)
– BUN-Creat ratio - hydration status. hypovolemia=increase (10:1)
• ULTRASONAGRAPHY – bladder scan: volume; kidneys: size, structure, obstructions, full bladder before procedure
• CT / MRI – relaxation techniques/anxiety management, MRI check list – no metal objects
• NUCLEAR SCANS – radioactive isotope injected through blood vessels of kidneys, scan provides info about kidney function,
GFR, drink plenty of fluids after to flush from system
• KUB xray – kidneys, ureters, bladder; size, shape, position, no specific prep
• IV UROGRAPHY / IV PYELOGRAM – contrast dye, outlines renal system/structural visualization, identifies abnormalities and
lesions, contrast dye prep: check allergies to iodine, shellfish, seafood, notify radiologist, health hx – meds/disease inc. risk,
check kidney function, tell pt they may experience temp feeling of warmth, flushing and have fishy flavor in mouth, post
procedure – maintain fluids, monitor for allergic reaction, I & O
• RETROGRAD PYELOGRAPHY – catheters into ureters through cystoscope and injects contrast agent, done if pts allergic to IV
contrast
• CYSTOGRAPHY – catheter into bladder and injects contrast agent to outline bladder wall, used to evaluate vesicoureteral
reflux and bladder injury
• RENAL ANGIOGRAPHY, ANGIOGRAM, ARTERIOGRAM – gives images of renal arteris, evaluates blood flow, differentiates
renal cysts from tumors, preop procedure for renal transplant.
– Laxative for better visualization, mark pulse site, VS, check sites for bleeding, hematoma, color and temp of
extremity, cold compress to site for edema/pain.
– Complications: hematoma, arterial thrombosis, altered renal function
• CYSTOSCOPIC EXAM - go through the urethra or make a small incision to visualize the urethra and bladder. After exam:
warm bath to relax pelvic muscle, Tylenol, blood in urine is common and clears up, low risk of infection but minimized with
drinking fluids. Notify physician if chills, shaking, cloudy/foul smelling urine, burning more than 2 days, blood in urine more
than 2-3 days, or difficulty emptying bladder.
• BIOPSIES – preop coag studies, NPO 6 – 8 hrs before, urine specimen; intra-op: breathe in and hold breath while needle is
inserted, sandbag under abd in prone position; post-op: IV fluids to clear kidneys and prevent clots, hematuria that clears in
24-48 hr
URINARY DISORDERS
URINARY INCONTINENCE
• An under diagnosed and underreported problem that can have significant impact on the quality of life and decrease
independence, which may lead to compromise of the upper urinary system. (WHY under diagnosed?)
• Urinary incontinence is not a normal consequence of aging
***MANAGEMENT: behavioral 1st choice: log, fluid intake, bladder training, avoid bladder irritants, Kegels, bladder
compression, vaginal cone retention exercises, transvaginal or transrectal electrical stimulation
• Pharmacological Thearapy
• Anticholinergic/ Antispasmotics: decrease urgency
• Oxybutynin (Ditropan)
• Propantheline bromide (Pro-Banthine
• Tolterodine tartate (Detrol)
• Oxybutynin (Oxytrol) OTC Patch
• Tricyclic antidepressants: Urge
• Amitriptyline (Endep)
• Decrease bladder contractions
• Has anticholinergic effects
• Pseudoephedrine (Sudafed)
• Stress incontinence
• Estrogen therapy-controversial
• Surgical Corrections-bladder lifting, bulking.
URINARY RETENTION
• Inability of the bladder to empty completely
– Leads to overflow incontinence
• Residual urine: amount of urine left in the bladder after voiding
• Causes: age, (decreased detrusor muscle activity), diabetes, prostate enlargement, pregnancy, neurologic disorders,
medications, postoperative (anal/perineal surgeries), anesthesia.
• Assessment:
– Time, how much urine, pain, distention, suprapubic region dullness with percussion, restlessness, agitation
(urinary retention), + post void residual.
• Complications: UTI, hydronephrosis, skin breakdown, renal stones, pyelonephritis, sepsis.
• Management:
– Prevent over distention of bladder
– Treat infection and correct obstruction
– Normal pattern
– Provide privacy, natural position for urinating, assisting patient to bathroom, bedside commode.
– Triggers: stroking the abd or inner thigh, tapping above the pubic area, dipping pts hands in hot water.
– Catheter
• S/S: visible painless hematuria; pelvic or back pain may indicate metastasis
• Diagnosis: cystoscopy, CT, ultrasonography, biopsy
• Treatment: surgery, BCG regimen-topical chemo, IV chemo with radiation.
• Kidney:
– Many produce no symptoms
– Manifestations:
• Dull flank pain
• Palpable mass
• Painless hematuria
– 30% have metastasis at diagnosis
– Compression: obstruction of urinary tract
• Management
– If encapsulated: nephrectomy
– Immunotherapy: IL2
– Renal artery embolization & chemotherapy
– Radiation
URINARY DIVERSION
• Reasons: bladder cancer or other pelvic malignancies, birth defects, trauma, strictures, neurogenic bladder, chronic
infection or intractable cystitis; used as a last resort for incontinence
• Cutaneous urinary diversion: ileal conduit, cutaneous ureterostomy, vesicostomy, nephrostomy
– Urine drains through an opening created through the abd wall into a bag
– Illeal conduit post care: skin barrier and disposable urinary drainage bag applied, Monitor output hourly <30ml is
problematic, stoma and skin care
• Continent urinary diversion: Indiana pouch, Kock pouch, ureterosigmoidostomy
– Part of intestines is used to create a new reservoir for urine.
– Catheter is used to drain the pouch
– Ureterosigmoidostomy – urine flows through colon and out rectum, more frequent urination
BPH
Risk factors: age > 40 and family history
Manifestations: hesitancy, recurrent bladder inf., retention, frequency, urgency, sm. amounts of urine voided, weak stream,
post urination dribbling.
Diagnostic tests – annually starting at age 50: DRE – enlarged, rubbery, non-tender, smooth prostate; PSA - < 4 ng/mL is
normal, performed prior to DRE because it can rise levels; transrectal US/needle or aspiration biopsy to rule out prostate
cancer
Management: depends on severity of obstruction or s/s; cath if cannot void
Pharmacological treatment:
Alpha-adrenergic receptor blockers: Relax smooth muscle of bladder and prostate
– Hytrin (tearazosin hydrochloride)
– Flomax (tamsulosin hydrochloride)
– Doxazosin(cardura)
– Alfuzosin(uroxatral)
– Side effects: dizziness, headache, fatigue, postural hypotension, rhinitis, sexual dysfunction
Anti androgens: decrease size of prostate
– finasteride(Proscar)
– Dutasteride (Avodart)
– Side effects: decreased libido, ejaculatory dysfunction, ED, gynecomastia, flushing
Post prostatectomy
• Hemorrhage-bleeding and hemorrhagic shock greatest risk. Red-pink → light pink 24 hours
• Infection
• Fluid balance maintenance.
• DVT & PE: early post-op ambulation & DVT prevention measures
• Pain: Incision/Catheter/ Bladder Spasms
• Obstructed cath: obstructed cath produces distention of the prostatic capsule resulting in hemorrhage.
• CBI: adjust rate
• If bladder spasms-administer meds-irrigate Reduced irrigation outflow-contact Dr.
• Record irrigation volumes and output
• Meds: analgesics, antispasmodics, abx, stool softeners for preventing straining.
• Discharge Instructions:
– Color of urine should progress to amber in 2-3 days
– Expected output is 150-200mL every 3-4 hrs
– Contact provider if unable to void.
– Avoid heavy lifting, strenuous exercise, straining, sexual intercourse as directed
KIDNEY DISORDERS
• Fluid and electrolyte imbalances
• Most accurate indicator of fluid loss or gain, in an acutely ill patient, is weight
• Also monitor I & O
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
AKI – acute kidney injury / failure – rapid loss of renal function r/t kidney damage
Causes: hypovolemia, hypotension, reduced cardiac output and heart failure, obstruction of kidney or lower urinary tract, obstruction of
renal arteries or veins
3 types:
PRERENAL
– Hypovolemia – Increased vascular resistance
– Volume shifts – Vascular obstruction
– Decreased cardiac ouput – Septic shock
– MI
INTRARENAL
– Acute tubular necrosis – Metabolic disorders
– Trauma – Glomerulonephritis
– Antibiotics – Vascular lesions
– Severe muscle exertion – Solvents, pesticides, heavy metals
– Infection
POSTRENAL
– OBSTRUCTION – ureteral, bladder, urethral
Phases:
Onset(Initiation)
– begins with initial insult and ends with oliguria
Oliguria
– Increase in the serum concentration of substances that are excreted out normally by the kidneys
– Uremic symptoms appear-hyperkalemia develops
Diuretic
– Gradual increase in urine output, GFR starts to recover
– Monitor for dehydration. With dehydration uremic s/s increase
Recovery
– 3-12 months to recover
– Improved renal function, normal lab values
– May have 1-3% reduction of GFR
Prevention:
Maintain / restore renal perfusion
Avoid nephrotoxins – NSAIDS, abx (gentamicin), radiocontrast dyes
Increase elimination of nephrotoxins – prehydrate with saline
Manifestations:
Lethargy
s/s of dehydration
CNS changes – drowsy, headache, muscle twitching, seizures
Hypotension, tachycardia, decreased cardiac output (per ATI)
Pt problems and management:
Fluid imbalance – diuretics, I&O, daily wt, edema
Electrolyte imbalance – s/s of hyperkalemia, treat with insulin + glucose, kayexalate, Na bicarb (metabolic acidosis), dialysis
Nutrition – highly individualized
– High carb meals
– Limit foods containing K and Phos: bananas, citrus fruits, juices, coffee
– Check lab work to determine and s/s of over and under hydration
– After diuretic phase – high protein and high calorie diet
Risk of infection – reduce metabolic rate b/c inc. catabolism, monitor for fever and s/s of infection, check lines, try to keep
foley’s out
Altered skin integrity – dry, breakdown, itching – use cool water, turn, cut nails, moisture
Pulmonary function – TCDB
Emotional support
CHRONIC KIDNEY FAILURE
STAGE DESCRIPTION GFR
125ml/min/1.73 m3 = normal
1 Kidney damage with normal or ↑GFR >/= 90
2 Kidney damage with mild ↓ GFR 60 – 89
3 Moderate ↓ GFR 30 – 59
4 Severe ↓ GFR 15 – 29
5 ESKD / ESRD < 15
Causes:
• Diabetes mellitus-#1 • Hereditary lesions
• Hypertension-#2 • Vascular disorders
• Chronic glomerulonephritis-#3 • Medications or toxic agents
• Pyelonephritis or other infections-#3 • Congenital
• Obstruction of urinary tract
Musculoskeletal manifestations:
↑ PO4
↓ Calcium
↑ PTH b/c ↓ Ca
Body does not respond normally to increased PTH-Ca leaves the bones=changes in bones
– Interventions: Diet modifications, Phosphate binders, Vitamin D analogs, Parathyroidectomy
TREATMENT:
• Prevent Progression/Maintain Function /Prevent Complications
– Diabetic: glucose control, BP control, CV risk reduction, limit exposure to risk factors that decrease kidney function, treat
manifestations, education
• Pharmacological
– Calcium phos binders: calcium carbonate, calcium acetate, sevelamer: bind to phos in the GI system, give with meals.
– Antihypertensives: variety-manage HTN and related heart issues
– Antiseizure meds: assess for twitching, headache delirium, seizure activity: meds: Valium or Dilantin.
– Erythropoietin: Epoeitin alfa IV or SQ. AE=HTN, increase clotting and decrease iron stores.
– Heparin to prevent clotting of lines, monitor H&H, assess serum iron. May get Venofer or INfeD. Contol HTN.
• Nutrition
– Regulate protein-restricted - Allowed protein must be high biologic value (diary, eggs & meats)
– Fluid intake: 500mL-600mL more than previous day’s urinary output.
– Calories from carbs and fats to prevent wasting
– Vit supplements-vit loss during dialysis also b/c of protein restriction.
PRIMARY GLOMERULAR DISEASE
GLOMERULONEPHRITIS – inflammation of the glomerulus bilaterally – causes porous capillaries that results in proteinuria and hematuria
• Immunologic abnormalities (most common) - Circulating antigen-antibody immune complex deposition-biochemical mediators of
inflammation
• Drugs or toxins
• Vascular disorders-ischemia
• Systemic diseases: Diabetes and Lupus
• Viral causes
ACUTE
Cause: Typically follows streptococcal infection, Consequence of immune reactions in the body to the infection, Antigen-antibody
immune complexes are formed and trapped in glomerular membrane, These cause an inflammatory response activating the complement
system and releasing inflammatory mediators, Leads to inflammation=glomerular capillaries becoming more porous=escape of plasma
proteins and blood cells into the urine.
Clinical manifestations: hematuria, proteinuria, decreased GFR, oliguria, HTN, orbital edema, lower ext. edema
CHRONIC
• Slow, progressive destruction of glomeruli
– Repeated acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia. Diabetes and lupus may also play a role.
– Deposition of immune complexes or formation of antibodies against glomerular basement membrane
• 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
Polycystic kidney disease – genetic disorder, no cure – manage s/s, palliative care, genetic testing / counseling
DIALYSIS
Who needs it: acid/base problems, electrolyte problems, intoxications, overload of fluids, uremic symptoms
HD – hemodialysis
Schedules:
– Traditional: 3x / wk, 3-4 hrs
– Daily: 6-7x / wk, 2-3 hrs
– Nightly: 3x / wk, 6-8 hrs
– Home HD canbe used – careful assessment of home environment is necessary
AV fistula – vein and artery anastomosed together , check for bruit and thrill – if absent notify Dr., do not use
arm for BP or blood draws
AV graft – synthetic tubing used to connect artery and vein, used when pt’s vessels are not suitable
Catheters – also used for dialysis, subclavian, jugular, or femoral
CV meds must be held prior to dialysis
Complications:
– Hypotension-fluid removal & associated N/V diaphoresis, tachy, dizzy.
– Cramping-fingers/toes/legs-rapid loss of F&E
– Bleeding-needle dislodgment
– Dysrhythmias-electrolyte/pH changes, removal of heart meds during HD
– Chest pain
– Air Embolism: rare!!
– Dialysis disequilibrium: rapid fluid shifts from ECF to ICF
Nutrition:
– Restrict protein, fluid, Na, K, Phos
– Need adequate calories to prevent protein wasting
– Vitamin and folic acid
PD – peritoneal dialysis
Schedule – 7 days / wk
Methods:
CAPD – continuous ambulatory peritoneal dialysis
– No machine
– Pt does 4-6 cycles/exchanges (exchange old dialysate for new, fill-dwell-drain) during the day
and dwells 1 cycle while sleeping
CCPD – continuous cycler peritoneal dialysis
– Machine used
– Cycles are done by machine while sleeping and pt dwells 1 cycle during the day
PD vs HD:
Patients who do not want HD
– Want self-care or have transportation issues, Live far from HD center
Patients who refuse HD
Patients who are unable to tolerate HD
– Hypotension/Angina
– No vascular access for hemodialysis
Dialysate solution:
Contain glucose
– 1.5%; 2.5%; 4.25%
– Hypertonic to blood
– Glucose concentration determines how much water will be removed from the blood
Osmosis
Contains electrolytes:
– Diffusion controls solute removal
Drain: wash hands, prepare environment, old fluid drained, fluid is measured and inspected
Fill: sterile fluid introduced to abd cavity via catheter by gravity
Dwell: fluid sits in peritoneal cavity for predetermined time, dialysate pulls fluid and wastes across the
peritoneal membrane and into the dialysate by osmosis and diffusion
Complications:
Peritonitis
– Abx through PD cath
– Observe the drained fluid
– Strict Aseptic Technique
Leakage at cath site initially when cath inserted
Bleeding
– Bloody drainage
– Should stop in 1-2 days.
– Common in young menstruating women
– Common in first few exchanges after new cath
Exit site infection
– Characterized: drainage, edema, redness, tenderness
– Notify nephrologist
– Treatment: C & S if drainage, antibiotics, remove catheter if no improvement
– Asses if catheter care being done properly
Clean q day: clean technique
Hyperglycemia
– Glucose absorbed from dialysate or insufficient insulin
– Characterized: increased blood glucose, weight, and thirst
– Treatment: insulin coverage, adjust glucose content of dialysate
Fluid deficit
– Removal of too much fluid
– Treatment: restrict activity until increase in BP, ↓ dextrose in dialysate, increase fluid intake
Fluid excess
– Not enough fluid removed
– Treatment: increase dextrose of dialysate, correct hyperglycemia if present, decrease fluid
intake
Other considerations
– High protein diet: continuous loss due to CAPD, monitor albumin levels
– Normally do not need to restrict intake of K, Na, and fluid
– Folic acid
– Increase fiber intake to prevent constipation – can cause obs of in/out flow
– Strict aseptic technique to prevent infection
KIDNEY SURGERY
PRE-OP: encourage fluids, abx for infection, labs, encourage pt to voice concerns
PERI-OP: assist with positioning
POST-OP: potential hemorrhage and shock, abd distention and paralytic ileus, infection, thromboembolism
– Assessment: include all body systems, pain, fluid and electrolyte status, and patency and adequacy of
urinary drainage system
– Diagnoses: ineffective airway clearance, ineffective breathing pattern, acute pain, fear and anxiety,
impaired urinary elimination, and risk for fluid imbalance
– Complications: bleeding , pneumonia, infection, and DVT
– Interventions:
Pain relief measures, analgesic medications
Promote airway clearance and effective breathing pattern, turn, cough, deep breathe, incentive
spirometry, positioning
Monitor and maintain patency of urinary drainage systems
Use strict asepsis with catheter
Monitor for signs and symptoms of bleeding
Encourage leg exercises, early ambulation, and monitor for signs of DVT
TRANSPLANT
PRE-OP: prepare pt, optimize physical status, tx infection
POST-OP: maintain homeostasis, s/s of rejection – oliguria, edema, fever, inc BP, wt gain, swelling or tenderness
over transplant area, rise in serum Creatinine
Immunosuppression: life time, started pre-op, steroids, anti-rejection meds: cyclosporine (no grapefruit juice)
mycophenolate, tacrolimus