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nctc med surg Renal
| Question | Answer |
|---|---|
| What is a UTI? | a common infection of the urinary tract-may involve the urethra, bladder or kidneys –urethra-urethritis –bladder-cystitis –kidneys-pyelonephritis •can be bacterial, viral, fungal or by yeast |
| What can cause a UTI? | micro-organisms •trauma •sensitivity to vaginal deodorants, bubble baths •tight clothing, synthetic undergarments •dehydration |
| What are the S/S of UTI? | Urethritis - frequency, urgency, dysuria, bladder spasms •Cystitis - same as above with tea colored urine, incontinence, low grade fever, fatigue and pelvic discomfort |
| What substances if found in urine, would be NORMAL? | Water •Na •K •Cl •Urea •Creatinine •Uric acid •Ammonia |
| What substances, if found in urine, would be considered ABNORMAL? | Glucose •Protein •WBC’s •RBC’s •Bacteria •Ketones |
| What is another name for protein in the urine? | Proteinuria |
| What is pus in the urine and is it normal? | Excess WBC’s in urine •Abnormal •Pyuria |
| What does the term “hematuria” mean? | Blood in the urine |
| What is a normal renal system made up of? | Urethra •Bladder •Kidneys •Ureters |
| What is the function of the kidneys? | Regulatory: regulate F & E •Excretory: excrete wastes •Hormonal: stimulate production of RBC’s |
| What is the smallest functional unit of the kidney called? | Nephron |
| Glomeruli | Filtration - F & E are filtered out of the blood –Plasma proteins too big, so they stay Final product - called glomerular filtrate, contains water, Na, K, Ca, Mg, Cl, bicarb, phosphate, urea, uric acid and amino acids –normal GFR: 100-125 ml/hr |
| Renal tubules | Some products go back into the blood stream: water and some electrolytes Some are not reabsorbed so are excreted: urea, Cr, uric acid –This is how & where acid base balance is maintained: tubules excrete or retain bicarb |
| Erythropoietin | is secreted by kidneys to stimulate RBC production –decreased O2 in blood triggers this response –pt’s with renal failure are deficient in erythropoietin |
| Antidiuretic hormone | regulates BP through volume control –when dehydrated, ADH released by the brain to signal the renal tubules to retain water |
| Renin-Angiotensin system | regulates blood flow to kidneys –when blood flow to kidneys is reduced, renin is released and acts on angiotensinogen - converts to angiotensin I then II which is a powerful vasoconstrictor: raises BP |
| What is cystitis? | inflammation of the bladder |
| What can cause cystitis? | bacterial contamination •prolonged immobility •renal calculi •urinary diversion •indwelling catheters |
| In which gender is cystitis more commonly seen and why? | Women –urethra closer to the vagina and rectum |
| What are the S/S of cystitis? | same as urethritis plus –nocturia –incontinence –low grade fever –pelvic discomfort |
| How can a routine U/A be collected? How much is needed for an accurate result? | cleanse perineum •void into toilet, stop stream, then void in cup •minimum depends on lab: 30-50 cc |
| If a collected U/A cannot be delivered to the lab immediately, what special handling is necessary? | place on ice or in the refrigerator |
| What information can you obtain from a routine UA? | Color •pH •Specific gravity (1.003-1.035) •Glucose •Protein •Blood •Ketones •Bilirubin •Presence of cells, casts, crystals, bacteria |
| If you have a choice, which voiding of the day would be the BEST specimen for a routine U/A? | first void of the day |
| What is a urine C & S? | Urine culture and sensitivity |
| How is a urine C & S collected? | cleanse perineum •start void - stop stream •void in cup - stop stream •finish in toilet |
| What is the medical treatment for cystitis? | Meds: –sulfasalazine – Bactrim –Macrodantin •Correct cause |
| What should patient teaching for a cystitis patient include? | warm sitz baths comforting •increase fluids - 30 ml/kg •void frequently •drink cranberry juice •take all of ATB even if have no s/s |
| What is a cystoscopy? | direct visualization of interior of the urethra, bladder and ureteral orifices •for treatment of lesions, remove calculi, tumors, control bleeding •most commonly done with local and sedation |
| If general anesthesia is used for a cystoscopy, what preparation is required? | NPO for 6-8 hours •Enemas •Pre-procedure meds to reduce anxiety |
| If local anesthesia is used for a cystoscopy, what preparation is required? | NPO for 6-8 hours •Enemas •Pre-procedure meds to reduce anxiety same as above except may have liquid breakfast |
| What should a patient expect to experience after a cystoscopy? | urine may be pink or blood tinged, will gradually return to normal, in 24-48 hrs •may have back pain, burning on urination, frequency, bladder spasms •rare - severe abd pain from bladder perforation |
| What can a patient do to relieve the normal discomforts following a cystoscopy | Belladonna & Opiate (B & O) suppositories |
| What is pyelonephritis? | •an inflammation of the renal pelvis •may affect one or both kidneys •may be acute or chronic |
| What can cause pyelonephritis? | ascending bacteria (see pg. 1160) •blood borne (septicemia) •reflux •recurrent infection |
| What S & S are associated with acute pyelonephritis? | High fever, chills –N/V –Dysuria –Severe flank pain |
| What S & S are associated with chronic pyelonephritis? | Bladder irritation –Chronic fatigue –Slight ache over both kidneys |
| Why would a patients BP be elevated if he has acute pyelonephritis? | pain |
| Why would a nephritis patients temperature be elevated? | bacterial infection |
| When visualizing a urine specimen, what should a nurse be assessing? | color •odor •clear or cloudy •hematuria •amount |
| What is a KUB? | x-ray of the kidneys, ureters and bladder. |
| What patient preparation is needed for a KUB ? | None |
| What is intravenous pyelography (IVP) | radiographic dye injected IV to see how dye is concentrated by kidneys and then excreted •pictures taken at 5-15 min intervals •observing for stones and abnormalities |
| What patient preparation is needed before an IVP and why? | Enemas or laxatives as ordered •Fluids only, or NPO 8-10 hrs before procedure •Check for allergy to iodine or shell fish •Tell pt they’ll feel a warm flush feeling |
| What patient teaching is essential following an IVP? | encourage fluids to flush out dye •s/s of allergic response: itching, hives, wheezing, resp distress |
| What is renal calculus? | a calculi in the kidney or renal pelvis |
| What are some other names for renal calculi? | kidney stones •nephrolithiasis |
| How does a kidney stone differ from ureteral calculi? | Ureteral calculi are in the ureters instead of the kidneys or bladder |
| Why would a urinary (renal) stone present a problem for the body? | causes severe pain •may cause an obstruction |
| What causes renal calculi? | dehydration leads to concentrated urine •stones precipitate from calcium, phosphorous, uric acid or magnesium •influenced by diet, urine components and activity |
| What are the usual S/S of renal calculi? | Pain –Acute pain radiating to groin suggests it’s in the ureters –Dull flank pain suggests it’s in the renal pelvis •N/V •Hematuria •Possible S/S of UTI |
| Explain the correlation between immobility and the development of renal calculi? | immobility allows for urine to settle in the kidneys •crystals precipitate and begin to gather together creating the stone |
| What other factors could favor the development of stone formation? | Hyperparathyroidism •Excessive intake of Vit C or D •Urinary stasis |
| What nursing interventions are appropriate for a patient with renal calculi? | assessment • pain control • encourage fluids • strain urine and examine for stones- send to lab if recovered |
| What is an extracorporeal shock-wave lithotripsy (ESWL)? | a device called a lithotriptor delivers a series of shock waves to disintegrate the calculi –pt may be lowered into a tank of water –sedated with general anesthesia or conscious sedation –shock waves delivered to flank area |
| Would you expect the infection potential from a lithotripsy procedure to be high or low? Why? | Low •It is a non-invasive procedure |
| What should a patient expect to experience as a normal post-lithotripsy side effect? | urine may be pink to cranberry, gradually corrects to yellow/amber •may have discomfort - pain meds ordered |
| What is a lithotomy? | •Incision in organ or duct to remove stone •Pre-op, post-op surgical NI |
| What discharge teaching would be important for this patient in order to prevent future renal stones? | High fluid intake: 3 L/day –including 2 glasses of water at bedtime, and 2 when awaking at night to void •Frequent urination: q 2-3 hrs •Dietary restrictions of calcium or purines, •Regular exercise •Meds or diet to alter urine pH |
| What is hydronephrosis? | stretching of renal pelvis due to obstruction of urine outflow •condition due to untreated obstruction: stenosis, stones, strictures •usually treatable once detected –causes permanent damage if untreated |
| What are the S/S of hydronephrosis? | usually asymptomatic •flank pain •back pain •s/s of renal failure •s/s of UTI |
| What are the treatment options for hydronephrosis? | Foley –for BPH •Treat cause –ESWL •Nephrostomy tube |
| List the nursing care for a hydronephrosis patient. | I & O •Make sure Foley tube has no kinks or clamps to avoid continued hydronephrosis |
| How much of a systolic BP is needed to maintain kidney function? | 70 mm/Hg systolic |
| What is a nephrectomy? | removal of kidney |
| Can a person survive with only one kidney or will he need dialysis post-op? | yes •no need for dialysis, if remaining kidney is healthy |
| Why does a nephrectomy patient pose a high risk for post-op hemorrhage? | kidneys are very vascular with a large renal artery |
| What nursing interventions are appropriate for a post-op nephrectomy patient? | monitor VS q 1-4 hrs for first 24-48 hrs •pay close attention to urine output, respirations, and bowel function •risk for pneumonia and paralytic ileus •pain control - flank pain •splint during coughing |
| What is a ureteral catheter? | Catheter threaded thru ureter into renal pelvis –permits urine to flow thru swollen ureter after traumatic surgery –“ureteral stent” |
| nursing interventions for ureteral catheter | keep free of kinks, do not clamp •pressure builds up in kidney –irrigate max w/5ml lukewarm, sterile saline •instill slowly •must have Dr’s order –strict, ACCURATE I&O |
| What is a nephrostomy tube? | Inserted thru flank incision directly into kidney pelvis •Done for complete obstruction •Allows healing of surgical area |
| nursing interventions for a nephrostomy tube? | ensure continuous, unobstructed flow –no kinks, no clamp –sterile drsg chg, skin care –irrigate with small amt sterile saline, no more than 5ml •Must have Dr’s order –accurate I&O –daily weights –notify Dr. immediately if tube dislodged |
| What should your discharge teaching include for a nephrectomy patient? | wound care •use asceptic tech to decrease risk for infection •pain control •protect remaining kidney •no contact sports to avoid trauma •avoid others who are infectious •plenty of fluids •no lifting for 6-8 weeks •take meds as instructed |
| What is the most common initial symptom of a bladder tumor? | painless intermittent hematuria |
| If this initial symptom is ignored, what other S/S may develop? | bladder irritability, infection, dysuria, frequency, urgency, decreased stream of urine |
| Name the risk factors contributing to bladder cancer: | * Tobacco * Occupational exposure * Aniline dyes found in industrial compounds * Sewage * Tryptophan (amino acid) |
| What does the term “malignancy” mean? | * Progressive * tendency to invade other tissues |
| What does the term “metastasis” mean? | * cancer spreading to different sites |
| What diagnostic test is definitive for cancer? | * biopsy of the tumor |
| What is a cystectomy? | * removal or resection of bladder |
| Instead of a cystectomy to remove a bladder malignancy, what other treatment might be employed? | * intravesical chemotherapy |
| What is urinary diversion and why is it necessary following a cystectomy? | * Creation of a urostomy, an alternate route for urine to leave the body * Urine must drain via another route |
| ileal conduit | portion of ileum resected and ureters implanted in ileum. One end closed and open end brought out to the surface to drain into a bag. |
| cutaneous ureterostomy | ureter brought out to the surface of the abdomen. |
| cutaneous ureteruretostomy | one ureter attached to the other then brought out to the surface. |
| What is a ureterosigmoidostomy and what are its advantages and disadvantages? | * Ureters are re-routed to the sigmoid colon, urine is excreted through the rectum * Advantage: no external abdomen stoma * Disadvantage: high risk of infection. |
| What is a cutaneous ureterostomy? | * when one or both ureters are brought out through an opening in the abdominal wall or flank * often 2 ureters are joined surgically so that only one stoma is needed |
| What is an ileal conduit? | * made out a portion of the small intestine * most common type of urinary diversion |
| Why will urine flow be continuous with an ileal conduit? | * no bladder as holding area |
| What are some post-op complications that can occur in a patient with a cystectomy? | * Hemorrhage * Infection * Paralytic ileus * Peritonitis |
| What are the S/S of peritonitis? | * Pain over the affected area * Rebound tenderness * Abdominal rigidity * Distention * Rigidity * Tachycardia * N/V |
| What is a urinary diversion appliance? | * urostomy bag |
| Why is it important to properly fit and properly apply a urinary diversion appliance? | * to prevent maceration and infection |
| Why is it important to empty an ileal conduit drainage bag before it is filled to capacity? | * prevent reflux * decrease risk for infection |
| What would be considered a normal finding when emptying the bag for a pt w/ileal conduit? | * Mucous, produced by the lining of the ileum, will be present in the bag |
| How can you assist a patient with a cystectomy cope with his altered body image? | * be matter of fact when dealing with the stoma * be understanding of feelings * encourage normal ADL’s * can soak bag in vinegar if has odor * encourage to care for ostomy himself |
| Functional incontinence | inappropriate voiding in the presence of normal bladder function |
| Overflow incontinence | loss of urine w/full bladder |
| Stress incontinence | involuntary loss of urine during physical exertion (cough, sneeze, running) |
| Reflex incontinence | reflexive contractions of bladder due to spinal cord injury or radiation |
| Total incontinence | loss of control over voiding, cause may be unknown |
| Urge incontinence | involuntary loss of urine, usually shortly after a strong urge to void |
| Transient incontinence | temporary loss of control over voiding |
| What are the risks of an indwelling foley catheter? | * Infection * #1 cause of nosocomial infections * Reflux |
| What nursing interventions are imperative for a pt with a foley? | * secure tubing to the patient’s inner thigh -prevents back & forth motion * handle gently to avoid trauma * keep bag below level of bladder to prevent reflux * keep system close * peri care 2x/day & after BMs * good hand washing |
| Should foley catheters be irrigated regularly with normal saline? Why or why not? | * NO * Opening the system introduces risk of infection |
| When foley catheters must be irrigated, what technique must be employed? | sterile |
| What is bladder training and why is it necessary before discontinuing a foley that has been in place week or longer? | * Clamp tubing until feels urge to void then unclamp * Increases sphincter control |
| What is glomerulonephritis? | inflammation of the capillary loops in the glomeruli |
| How does glomerulonephritis alter normal renal physiology? | * antigen-antibody reaction results in inflammation of glomeruli * scar tissue forms * permeability increases * proteins get through and are excreted in the urine * GFR decreases * nitrogenous wastes increase in the blood * BUN & creatinine increase |
| Why is Major Ed Deema’s strep throat infection of 16 days ago relevant to his present illness? | * most common type of glomerulonephritis follows strep infection of resp tract * group A beta-hemolytic strep |
| What is the S/S of glomerulonephritis? | * tea colored urine * periorbital edema * anasarca * increased BP * hypervolemia * oliguria |
| What is a BUN and what does it measure? | * blood urea nitrogen * kidney function * indicates ability of kidney to excrete urea, an end product of protein metabolism |
| What are the two BEST lab tests to evaluate kidney function? | * Serum creatinine * Urine creatinine clearance |
| What is the purpose of weighing a glomerulonephritis patient daily? | * assess kidney’s ability to excrete fluids |
| What medical treatments and nursing interventions are appropriate for a glomerulonephritis patient? | * Diuretics * Antihypertensives * ATB if streptococcal infection evident * Bed rest during acute phase to treat heart failure * Activity restricted as long as blood or protein in urine * Activity increased as FVO is resolved * Consistent follow up needed |
| When will you expect to see a diuresis in acute glomerulonephritis? | only with diuretics |
| Which assessment observations would indicate to you that a glomerulonephritis patient is improving? | * decreased edema * lungs clear * decreased BP - return to normal * increased activity tolerance |
| What is the danger of chronic glomerulonephritis? | * renal insufficiency * leads to renal failure * may need dialysis |
| If a patient with a foley has a low urine output into the drainage bag, what should be done by the nurse to verify that the kidneys are the cause of this? | * assess that there are no kinks in the catheter * the catheter should be secured to the inner thigh with tape and tubing looped on bed (see figure 65-2, pg. 1156) * flush with sterile NS to assess patentcy (must have order) |
| How many cc’s of urine per hour would indicate normal kidney function? | * 30 cc/hr |
| What is acute renal failure? | * a condition that decreases blood flow to the kidneys and impairs renal function * rapid onset that is usually reversible |
| What are the causes of renal failure? | * May be prerenal, intrarenal or postrenal * See table 64-3, pg. 1140 * Prerenal * caused by decreased BP, < 70 systolic * Hypovolemia may be cause of hypotension |
| acute renal failure - caused by nephrotoxic agents | * ATB, heavy metals cleaning compounds, pesticides, poisonous mushrooms |
| acute renal failure- * kidney infections | * pyelonephritis * glomerulonephritis * polycystic kidneys |
| acute renal failure - of renal arteries | * atherosclerosis * sickle cell anemia |
| acute renal failure? | * HTN * DM * Direct trauma to kidneys. |
| Postrenal causes of ARF | * obstruction beyond kidneys that causes urine to back up * ureteral calculus * prostatic hypertrophy |
| What lab tests would indicate that the pt is in acute renal failure? | * elevated serum creatinine (>0.6-1.2) * not influenced by diet, hydration, nutritional status or liver function * creatinine clearance * <150mg/24hr: M, <250mg/24hr: F shows the rate at which the kidneys remove creatinine from the blood |
| What medications can cause acute renal failure? | * Nephrotoxic antibiotics * Anti-inflammatories: Toradol Always look up meds w/renal pts, especially new meds |
| What does the term “oliguria” mean? | very little urine output |
| What does the term “anuria” mean? | * no urine output |
| What are the phases of acute renal failure? | * Initiation/onset * Oliguric phase * Diuretic phase * Recovery phase |
| acute renal failure: Initiation/onset | * Acute tubular necrosis * increased BUN & serum creatinine * normal to decreased UO |
| acute renal failure: Oliguric phase | * UO <400 cc/day * BUN, creatinine, phosphorous & potassium increase * Calcium & bicarbonate decrease * Hypervolemia: HTN * Waste products retained |
| acute renal failure:Diuretic phase | * UO >400 cc/day, may be >4000 cc/day * very few waste products eliminated * near the end of this phase the kidneys start to eliminate urea, nitrogen, creatinine, potassium and phosphorous & retain calcium & bicarb |
| acute renal failure:Recovery phase | * serum electrolytes return to normal * may take over a year or more * may have permanent renal insufficiency: loss of 80% of function |
| What is pruritis? | * itching of the skin * caused by dryness due to decreased oil gland production and perspiration |
| What is peritoneal dialysis? | * the patients own peritoneum is the semi permeable dialyzing membrane * fluid instilled and waste products drawn to fluid then fluid is drained off |
| What is the name of the fluid that is used for peritoneal dialysis? | * dialysate |
| How much dialysate is used per exchange? | * 1500 - 3000 cc * Remains in peritoneal cavity for 4-10 hours * Drained over 20 minutes Repeated 4-5 times a day |
| Why is it important to warm the dialysate with aqua-K pads before infusing into the peritoneal space? | * cold fluid causes abdominal cramping |
| What complication would you be monitoring for in the peritoneal dialysis pt? | * Peritonitis infection of the peritoneal lining |
| What is the S/S of uremia? | * uremia may be used interchangeably for end stage renal disease * the symptoms are the same as chronic renal failure |
| Nursing diagnoses in ARF | * Fluid volume excess vs. deficit * Decreased cardiac output * Disuse syndrome * RT immobility * Knowledge deficit * Anxiety |
| NI for pt with ARF | * Monitor fluid status continuously * Daily wt * FR (500ml=approx. 1lb) * Monitor VS * Monitor for: Pulm edema, HTN, uremic frost, pruritis, constipation, atelectasis, anxiety, fear of dialysis * Monitor labwork, F&E status |
| What is chronic renal failure and how does it differ from acute renal failure? | * Decreased renal function due to progressive & irreversible damage to the nephrons * ARF has sudden onset & is potentially reversible |
| Azotemia | the kidneys inability to remove waste products from the blood |
| Uremia | considered a “toxic” state, there is an accumulation of wastes in the blood, regardless of the amt. of UO |
| What conditions can cause chronic renal failure? | * most common: intrarenal conditions or complications of DM, HTN, & atherosclerosis |
| Why would fluid and electrolyte imbalances be common in chronic renal failure? | * patients are unable to excrete sodium and water, creating hypervolemia and hypernatremia * hypervolemia causes increase in BP and leads to CHF * few pts are “sodium wasters” and become hypovolemic and hyponatremic |
| What are the S/S of chronic renal failure? | * Azotemia * Increased serum BUN, Creatinine * Decreased creatinine clearance, decreased GFR * Hyperkalemia * Hypocalcemia * Metabolic acidosis * Insulin resistance * Anemia * Decreased immunologic function |
| What is an IVP and what pt teaching needs to be done before the procedure? | njection of radiopaque dye to visualize ability of kidneys to concentrate dye * check for iodine allergies restricted diet, fluids only, or NPO x 8-12 hrs prior |
| What is a renal biopsy? | * used to obtain renal tissue for direct microscopic evaluation * Open - with surgical incision in flank area * Closed - needle inserted under fluoroscopy to aspirate renal tissue |
| What must the nurse assess for post renal biopsy procedure? | * assess frequently for bleeding * will have a pressure dressing * VS q15 min x 4, then q30 min x 4, then q1hr x 4 * Hct & Hgb checked post procedure urine may be pink tinged |
| Describe a cystoscopy and what care is required post procedure. | * visualization of urethra, bladder & kidneys * I & O, VS, color of urine |
| What are Lasix and Bumex and why were they used on a chronic renal failure patient? | * diuretics * decrease edema & stimulate kidneys to produce urine |
| What effect does Lasix have on serum K+? | * flushes K+ out with Na+ & water |
| What 2 foods could be encouraged to treat low K+ for the pt at home? | * bananas, potatoes |
| How can an elevated K+ be treated? | * IV glucose with insulin * Na bicarb * Drives K+ back into the cells * Kayexalate * Draws K+ into the gut to be eliminated in the feces |
| What drug can be given to treat anemia and how does it work? | * Erythropoietin stimulates RBC production in the bone marrow |
| How is hypocalcemia treated? | * diseased kidneys lack enzyme that activates Vit D - unable to absorb Ca * treated with Ca supplements, active Vit D and phosphate binders * Aluminum hydroxide - Amphojel or Basojel * SE - hypophosphatemia and constipation |
| What is uremic frost? | * Ca++ phosphate crystals and urea accumulate on the skin causing itching |
| What common GI problems can occur? | * Stomatitis * Anorexia * N/V * Constipation Diarrhea |
| What is hemodialysis? | * blood removed from the body and circulated through an artificial kidney * removes excess fluid, electrolytes & wastes * dialyzed blood returned to pt |
| Why is it essential to weigh the pt both before and after dialysis? | * assess for loss of fluid |
| What nursing interventions are appropriate for a patient with chronic renal failure? | * pt teaching re: potential dialysis * need for vascular access * good oral care to avoid stomatitis no sugar if diabetic |
| When discussing his diet with a chronic renal failure patient, what foods should be eliminated? | * foods high in K, Na * low protein diet * fluid restrictions no sugar if diabetic |
| What dietary vitamins are important for a chronic renal patient? | multivitamin vitamin D |
| What is diabetic neuropathy? | * destruction of peripheral nerves due to free floating sugar * decreased sensation in periphery, burning sensation |
| Can a kidney from any willing donor be transplanted successfully in any recipient? | * Tissue from donor and recipient must match * Based on blood groups and human leukocyte antigens24. Why would immunosuppressive drugs such as Cyclosporin, be given to Ollie Guria pre-op and post-op? reduce the risk of rejection |
| What are the signs of kidney transplant rejection? | * fever * increased BP pain over location of new kidney |
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