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Nurs 342 - Week#1-3

Nursing in Health & Illness II: Renal, Urinary & Organ Transplantation

What are the causes of UTI? Usually colonic flora: e-coli, proteus, pseudomonas
What are the risk factors for UTIs? 1. Urinary retention 2. Female elderly 3. Sexual intercourse 4. Pregnancy 5. Poor hygiene 6. Immobility 7. Catheters
What are the common causes of nosocomial UTI? 1. Catheters--open track to the bladder 2. Catheters--poor aseptic technique used for insertion
What are the S/S of UTI? 1. Frequency, urgency, dysuria 2. Hematuria, pyuria, 3. Pain--perineal, suprapubic, flank 4. CVA tenderness
What are the remarkable lab values for UTI? 1. UA--presence of WBC's or bacteria; UA (cathed) "clean catch" culture & sensitivity 2. CBC shows elevated WBC's; fever, chills, malaise
What does a typical treatment protocol for UTIs involve? 1. Antibiotics—broad spectrum (Sulfamethoxazole/trimethoprim, Cephalosporin, Quinolone's), fluids—2-3 L q.d, acidify urine—cranberry, prunes...no caffeine/ETHOH, void q.2-3.h, hygiene
What is the tx for dysuria r/t UTI? Phenazopyridine (Pyridium); Urinary analgesic--turns urine orange—warn patients (Interferes with UA for glucose, etc)
What is the tx for a more severe UTI? Aminoglycosides—Gentamicin, Treat fever—acetaminophen, Fluids—PO or IV, Analgesics for pain
What is the tx for Chronic UTI or Pyelo? Monitor cultures, BUN, Creatinine, evaluate urinary tract for cause. Can lead to renal failure
Describe Pyelonephritis. More severe UTI, upper tract.
What are the S/S of Pyelonephritis? Same as UTI: 1. CVA tenderness, fever, chills, N/V. 2. Pain—ureter up to epigastrum, Constant or colicky. 3. UA—bacteria, WBC’s, WBC casts, RBC’s
What sort of teaching can help prevent UTIs? 1. Hydration 2. Hygeine—peri care 3. Void after intercourse 4. Cotton underwear 5. Acidify urine
Treating which sort(s) of obstruction(s) can help prevent UTIs? Stones, prostate
How can one treat neurogenic urinary retention to prevent UTIs? Self-catheterization (aseptic technique), cholinergics such as Bethanechol (Urecholine; avoid w/glaucoma/bowel obstructions)
What are disadvantages to indwelling vs. intermittent catheterization with respect to UTI prevention? Indwelling catheterization can cause biofilm colonization which can serve as a growth medium for bacteria/yeast.
Describe the implications for the use of Macrodantin (Nitrofurantoin). Macrodantin (Nitrofurantoin) chronically→urinary antiseptic Turns urine brown, Take with food or milk (gi upset). Treat acute UTI, prevent recurrent UTI in high risk
What are the risk factors for urinary retention? 1. Neurologic disease, injury 2. Obstruction—strictures, prostatic hypertrophy 3. Bed rest 4. Medication—anticholinergic side effects 5. Dehydration
What are some ways to encourage voiding? Normal position, privacy, time, running H2O, drink H2O, place hand in warm H2O, pour over perineum
What do we know about Cather Associated UTIs? 1. The longer a catheter remains in place, the greater the risk of UTI. 2. As of 2008 Medicare & Medicaid stopped reimbursing for care of CAUTI
How can we reduce the risks of CAUTIs (Cather Associated UTIs)? 1. Sterile technique 2. Proper specimen collection for accurate dx 3. Foley care--clean/secure 4. Drainage bag below catheter (not on floor) 5. Prompt removal of foley.
Describe the pathophysiology of glomerulonephritis. Inflammatory reaction after Strep.
What are the S/S of glomerulonephritis? Fever, chills, weak, N/V, HTN, generalized/periorbital edema (fluid overload), abd pain, flank pain, oliguria
What results would one expect from a client with glomerulonephritis? 1. gross proteinuria, hematuriacola colored urine, 2. Low serum protein, 3. High BUN, creatinine, 4. Azotemia may develop rapidly
What is a common treatment regimen for glomerulonephritis? 1 Penicillin—may continue several months 2. Bed rest in acute phase 3. Diet—low Na+, low protein, high CHO, restrict K+ as needed 4. Diuretics for edema, HTN 5. Antihypertensives 6. Plasmapheresis—reduce antibodies or 7. Immunosupressants
Describe nursing care for a client with glomerulonephritis. Monitor I & O, BP, edema, Electrolytes, BUN, Creat, Skin care for edema
Describe the pathophysiology of Nephrotic Syndrome. Strep infection->Glomerulonephritis: Severe proteinuria→ hypoalbuminemia→ low osmotic pressure→ edema→ hypovolemia→ stim. Na+ & H2O retention→edema
Describe the treatment for Nephrotic Syndrome. Goal: reduce inflammation. How? Corticosteroids, immunosuppresants (cytoxan), reduce fluid/salt, low/mod protein intake, high calorie, albumin or plasma IV to increase osmotic pressure, diuretics (aldosterone blocker: aldactone; K+ sparing)
What should a nurse taking care of a client w/ Nephrotic Syndrome be monitoring for? 1. Monitor fluid status— I & O, daily weight, Abd. Girth, BP, 2. Careful skin care, 3. Isolation (if WBC low), 4. Anticoagulants (hypercoagulability)—monitor, teach safety, 5. Bed rest in acute/early phase
Describe the long term management of Nephrotic Syndrome. 1. Repeated exacerbations/remissions. 2. Proteinuria decreases as azotemia worsens. 3. Usually ends in renal failure
Who has a higher risk of a urinary-tract lithiasis? Male, 30’s (20-55), Family history, prior history
What are some S/S of renal calculi? 1. Pain!! Renal colic—crampy pain, severe flank pain, CVA, radiates to low Abd, bladder, groin, testes, 2. Hematuria—gross or microscopic, 3. Nausea, vomiting, diarrhea, 4. Pallor, diaphoresis, anxiety, 5. May see S/S UTI
Describe the dx process for stones w/in the UT/kidneys. UA—hematuria, pH, crystals , Urine culture & sensitivity, ***Strain all urine*** KUB—flat Abd X-ray—may see stone, also CT scan, Cystoscopy—visualize stone, remove it, History—gout, uricosurics, meds which change urine pH, excess Ca++ intake
Describe the non-surgical method of removing a kidney/gall stone. Litholapaxy cysto, basket and crush stone Lithotripsy; Shock waves aimed at stone--breaks up stone, May take 6 weeks to pass, Teach—hydration, strain urine. Analgesics for renal colic, monitor for hematuria
Why would a physician impliment the use of a ureteral stent? Placed to bypass stone, prevent obstruction,
How does one record I/Os when a client has both a foley cath, AND a ureteral stent. Record output separate from foley cath.
What is an IVP? IVP—Intravenous Pyelogram; a diagnostics test for viewing calculi—lithiasis—stones
What are some nursing implications for an IVP? Inject contrast→outline kidney, ureters, bladder ****Allergies—iodine, fish ****Glucophage (Metformin)—must withhold for 2-3 days risks renal failure (pre-treat with Acetylcysteine). Non-emergency preparation—laxative the night before
What is the treatment for a kidney/gall stone? Almost 90% pass spontaneously. Acute care—symptomatic. Pain Control—Narcotics Fluids—PO or IV—at least 3 L/day ***Strain all Urine*** Antiemetics. Antispasmodics—anticholinergics. Warm bath, moist heat—relax pt. Bed rest abc if needed
What is appropriate client education for someone waiting to pass a kidney/gall stone? Take home meds, fluid intake, strain urine—bring in any passed stone or gravel
What are the nursing implications r/t post-op care for clients undergoing surgical removal of kidney stones? Similar to any Abd surgery; Observe for bleeding, drains—amt, color, some blood OK Color of urine—TCDB, leg exercises, TEDs, SCD’s VS-often dehydrated Oxygenation—TCDB Elimination: Foley cath—hygiene, I & O Pain Control—must TCDB, PCA, epidural
What are some signs of renal shutdown r/t stones? Oliguria, anuria, acidosis, confusion, hypertension, rising BUN, creatinine
What is the purpose for urinary diversion? Why? Removal of the bladder (cystectomy) due to cancer or trauma.
What are the different types of urinary diversions available to a client with bladder cancer (or trauma)? 1. Ileal Conduit or loop, 2. Ureterostomy, 3. Nephrostomy (all require appliance for urine)
Why would someone need to undergo nephrectomy surgery? Trauma, cancer, polycystic disease or donation of the kidney.
What are pre-op considerations for the nurse monitoring a client about to undergo nephrectomy surgery. Testing to assure remaining kidney is functioning.
List nursing considerations for a post-op nephrectomy client. • Flank incision—may be laparoscopic • Fluid & electrolyte balance is key • Monitor urinary output carefully! • TCDB and incentive spirometry • Adequate analgesia for deep breathing • Monitor Abd distention—paralytic ileus common
What are the nursing implications for a post-op client with a urinary diversion? 1. Assess abd wound 2. Monitor stoma—bleeding, drainage, 3. Monitor urinary output 4. Monitor bowel function (segment of bowel used to create diversion) 5. Risk of infection—wound, urinary
What kind of education would a post-op urinary diversion client need? 1. Care of ostomy—appliance, skin care, 2. Adjustment to body image change—Ostomate clubs, 3. Prevention & monitoring for S/S UTI: High fluid intake, Mucus in urine is normal. Collaborate with Enterostomal Therapy Nurse
What kind of teaching would a client with a continent diversion need? Self-catheterization: Irrigate pouch daily, no appliance, may wear small bandage on stoma for mucous or drainage
What is Acute Renal Failure? Acute Renal Failure: A clinical syndrome characterized by a rapid loss of renal function with progressive Azotemia
What is Renal Insufficiency? Renal Insufficiency: Reduced renal function—reduced GFR, elevated BUN/Creatinine (Chronic Kidney Disease)
What is Chronic Renal Failure? Chronic Renal Failure:Progressive, irreversible nephron destruction in both kidneys
What is End Stage Renal Disease? End Stage Renal Disease (ESRD)→GFR is < 15ml per minute
What is Azotemia? Azotemia: Accumulation of nitrogenous wastes (BUN) & serum creatinine
What is Uremia? Uremia: Renal decline leads to symptoms in multiple body systems
What is Oliguria? Oliguria: Decreased Urinary Output (UO) to <400ml/day
What is Anuria? Anuria: Complete suppression of urine formation by the kidney--<100 ml/24 hrs
What are normal values for BUN, Creatinine, and the BUN to Creatinine ratio? BUN: 8-25; Creatinine: .6 to 1.5; BUN to Creatinine ratio s/b about = 10:1
What is a normal creatinine clearance? 85-135
What are normal ABG values? pH 7.35-7.45, pO2 80-100 mmHg, pCO2 35-45 mmHg, HCO3- 22-26 mEq/L, O2 Sat 90-100%, Base XS -2 - +3 mEq/L
What are normal values for: Serum Osmolality, Urine Osmolality, and Urine Specific Gravity? Serum Osmolality: 280-297 mOsm/kg, Urine Osmolality: 50-1200 mOsm/kg, Urine Specific gravity: 1.010 – 1.022
Describe what is happening when a client experiences prerenal acute kidney failure Diminished renal perfusion: Circulatory volume depletion, Hemorrhage, GI losses, Burns, Sepsis, Diuretics, CO decrease (MI, CHF), Afferent arterial pressure, Renal vascular obstruction
Describe what is happening when a client experiences intrarenal-cortical acute kidney failure Renal capillary swelling: Vascular: malignant hypertension Infectious: streptococcal Immunologic processes – Goodpasture’s syndrome, Systemic Lupus
Describe the radiological tests used for renal failure diagnostics. • Abdominal X-ray (KUB) • Intravenous Pyelogram (IVP) • Renal Scan • Renal Arteriography • Diagnostic Ultrasonography • Percutaneous Renal Biopsy for Renal Cancer
What causes intrarenal-medullary acute renal failure? Prolonged ischemia, MAP < 60mm Hg for over 40 min. secondary to massive hemorrhage, shock. Nephrotoxic Injury. Antibiotics, NSAID’s, other drugs, Contrast dyes
What causes postrenal acute renal failure? Obstruction to outflow, Ureteral obstruction, Prostatic hypertrophy, Renal calculi, Bladder infection Extraurethral – abdominal tumor
What is the most common type of acute renal failure? Intrarenal—due to ischemia or nephrotoxins
Created by: scottheadrick