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medsurg exam 4
urinary tract disorder pt 1
| Question | Answer |
|---|---|
| function of kidney | maintains homeostasis |
| how does kidney maintain homeostasis | Filters blood and creates urine Maintains blood volume Maintains BP Maintains blood composition Maintains body and blood pH Synthesis of calcitriol (the active form of vitamin D3 Produces erythropoietin (stimulates the bone marrow to produce RBCs) |
| ureters | approx 25-30 cm long |
| bladder | inner lining made up of epithelial cells |
| bladder measurements | urge to void: 150ml fullness: 400ml |
| urethra | male: 20cm long female: 4cm long opening: meatus |
| acute kidney failure prevelance | 5% -7% of hospitalized patients develop AKF Up to 30% incidence in critical care patients |
| mortality of AKF | 60% in critically ill pts |
| older adults develop AKD more frequently because | Higher incidence of serious illness Hypotension Major surgeries Diagnostic procedures Treatment with nephrotoxic drugs |
| causes of AKD may be | pre-renal intra-renal post-renal |
| pre renal AKF | Caused by conditions that affect blood flow and perfusion to kidneys |
| conditions that can cause pre renal AKF | hypotension, hypovolemia, hemorrhage, HF, cardiogenic shock, low cardiac output |
| intra renal AKF | Caused by direct damage to the kidneys such as infections, toxins, drugs, inflammation or reduced blood supply |
| if pt in intra renal AKF then they cannot be on | vanc or NSAIDs |
| post renal AKF | Sudden obstruction of urine flow due to enlarged prostate, calculi, tumor, or injury |
| diagnostic lab tests in kidney disease | increased serum creatinine increased BUN decreased GFR decrease creatinine clearance CBC ABGS - metabolic acidosis Electrolytes - high K, high PO4, high or low Na Urine creatinine Urinalysis - proteinuria and RBC, and if infection then WBC |
| diagnostic tests in kidney disease | KUB(Kidney, ureter, bladder) x-ray CT scan and MRI Renal Ultrasound Kidney Scan Biopsy |
| how larger must stones be to be seen on KUB xray | larger than 2mm |
| CT scan can show | CKD |
| renal ultrasound can show | dilated renal calyx |
| IVP (intravenous pyleogram) | inject dye and you can see the flow of urine |
| renal biopsy shows you | acute vs chronic |
| treatment for AKF | Identify and treat underlying cause Prevent additional kidney damage Maintain fluid and electrolyte balance |
| obstruction of urinary tract location | hydronephrosis, hydroureter, bladder outlet |
| hydronephrosis | dilation of renal pelvis |
| hydroureter | dilation or ureter |
| problem can be | acute or chronic |
| acute | reflux |
| chronic | kidney damage (enlarged prostate) |
| diagnosis of AKD through | Catheterize for residual (>400ml = straight cath) BUN, creatinine Electrolytes Cystoscopy Intravenous Pyelogram (IVP) Renal ultrasound CT scan |
| treatment of AKD | Dilation or removal of occlusion Treat the underlying problem: structural (congenital), renal calculi (stone formation), prostatic hyperplasia |
| If undiagnosed, chronic can lead to | renal failure and kidney damage |
| Manifestations of Hydronephrosis depend on | how rapidly it develops |
| if the Hydronephrosis is a sudden blockage, then they will have | intense pain btwn flank, n/v |
| if the Hydronephrosis is in the bladder, then they will have | changes in voiding, hesitancy, urgency, dribble problems, and incontinence |
| BPH | benign prostatic hyperplasia |
| BPH is commonly | enlarged prostate |
| incidence rate of BPH | 50% men > 50 yrs 75% men > 70 yrs |
| what causes BPH | Increase in the number of epithelial cells and stromal tissue within the prostate |
| primary cause of BPH | endocrine changes associated with aging process |
| BPH manifestations (KNOW) | initially decrease in urinary flow |
| as obstruction increases in BPH, | Decrease in force of stream (early symptom) Hesitancy in initiating stream Dribbling upon completion Urinary retention |
| diagnosis of BPH | History Digital (rectal) exam Urinalysis Urine C & S Creatinine Urinary flow test Post void residual R/o prostate cancer (PSA) Transrectal ultrasound Prostate biopsy Cystoscopy |
| dx of BPH: history | when it starts |
| dx of BPH: digital (rectal) exam | use finger to check for enlargement |
| dx of BPH: Urinalysis Urine C & S | check for infection |
| dx of BPH: urinary flow test | urinate into receptical, measures strength and amount of urine flow, tells you if worse or better |
| dx of BPH: post void residual | able to fully empty? |
| dx of BPH: transrectal ultrasound | probe into rectum to measure |
| BPH medical management: alpha blockers examples | Doxazosin (Cardura) Terazosin (Hytrin) Tamsulosin (Flomax) |
| how do alpha blockers work | relax smooth muscle in prostate and bladder neck, and decreases blockage of urine |
| side effects of alpha blockers | orthostatic hypotension, ejaculation changes |
| BPH medical management: 5-alpha reductase inhibitors examples | Dutasteride (Avodart) Finasteride (Proscar) |
| how to 5-alpha reductase inhibitors work | inhibit hormone responsible for enlarging prostate, takes longer than alpha blocker |
| side effects of 5-alpha reductase inhibitors | ejaculation or erectile dysfunction, decreased libido |
| whats important to know about 5-alpha reductase inhibitors | wear gloves if women at child birthing age, keep caregivers educated |
| BPH surgical treatment | Transurethral resection of the Prostate (TURP) Laser prostatectomy |
| how does TURP work | burns away prostate tissue to decrease the amount of prostate tissue Removes the overgrowth of prostate tissue |
| what is needed after a TURP | Large 3-way foley used after continuous irrigation |
| Laser prostatectomy | Laser is used to excise tissue through urethra |
| turp surgery requires | pre op prep patient education! normal fluid and electrolyte balance |
| continuous bladder irrigation (CBI) are | sterile 3 way caths that require an order |
| why are CBI used | for post op bleeding, since there will be clots which you don't want to occlude |
| irrigation system | solution goes from bag down into bladder and then comes out into the catheter drainage bag |
| drainage color from CBI | clear and light pink |
| if CBI drainage is red, what should you do | increase irrigation |
| if there is too much fluid in the bladder, what can happen | it can be painful and cause bladder spasms |
| post op turp | Medicate for pain Medicate for bladder spasms Administer antibiotics Instruct patient not to strain to void or have BM Monitor for TURP syndrome |
| why should you instruct patient not to strain to void or have BM | because it can cause bladder to go into spasms |
| what is turp syndrome | it occurs because regular water is used in the OR so the pt can become fluid overload and become hyponatremic |
| S&S of hyponatremia from turp syndrome | confused, decreased Na, decreased Hct, HTN, bradycardia, nausea |
| nursing interventions for post op turp | Cough, turn and deep breath q 2h Incentive Spirometer SCDs Ambulation IV fluids until able to take oral Observe for abdominal distension, ileus |
| transurethral needle ablation is used to treat | BPH by heating the tissue, causing necrosis |
| Urolithiasis aka | urinary calculi |
| urinary calculi are the most common cause of | upper urinary obstruction |
| urinary calculi are | stones made of minerals or acids |
| where do urinary calculi form | Renal pelvis (nephrolithiasis) Ureter (ureterolithiasis) Bladder |
| kidney stones are more prevalent in | southeastern U.S. (florida) because many old people live there and it is hotter so urine is more concentrated |
| risk factors for kidney stones | Metabolic Climate Diet Genetic Factors Lifestyle- lack of exercise Urinary Tract Infections |
| metabolic risk factors for kidney stones | hyperparathyroid, diabetes |
| climate risk factors for kidney stones | warmer = more dehydrated |
| diet risk factors for kidney stones | increased with animal proteins, sugar, Ca supplement, high Na, oxite |
| patho of kidney stones | urine saturation urine pH stasis production of matrix |
| urine saturation effects on kidney stones | Urine becomes supersaturated Minerals precipitate, small crystals grow |
| alkaline urine pH | calcium phosphate stones |
| acidic urine pH | uric acid stones |
| stasis | if theres urine thats not moving, that will lead to crystal formation |
| production of matrix | mucoproteins that trap crystallites |
| types of stones | calcium oxalate calcium phosphate struvite uric acid cystine |
| struvite stones | related to uti, bacteria, women |
| uric acid stones are due to | high levels of uric acid, high purine diets |
| cystine stones | adolescents, hereditary |
| hereditary aspect of cystine stones | genetic disorder of AA cystine transport |
| points of obstruction from renal calculi | narrow areas in ureters |
| narrow areas in ureters | Ureterpelvic juntion Sacroiliac junction Ureterovesical junction |
| assessment of kidney stones (KNOW) | !!!Sudden, sharp pain radiating to flank area Nausea & vomiting Chills, Fever Hematuria |
| lab diagnostics of kidney stones | U/A, C&S 24 hr urine Measure Ca, Phos, uric acid levels Microscopic Crystals Urine pH alkaline with calcium phosphate Urine pH acidic with uric acid stones Urinary tract infection- struvite stones Elevated WBC’s |
| U/A, C&S to dx kidney stones to make sure | the symptoms aren't due to UTI |
| diagnostics of kidney stones | KUB- stones must be larger that 2mm IVP - to check flow of urine CT Scan Renal Ultrasound |
| nursing management of kidney stones | Control Pain Tamsulosin Force fluids Void q2h Strain all urine Dietary Changes |
| control pain from kidney stones with | NSAIDs if possible, if not then give opiods |
| tamsulosin works by | relaxing smooth muscle to make wider and pass stones |
| why do you strain all urine | to see if they passed the stones so you can check pathology |
| uric acid stones are treated with | allopurinol - decreases level of uric acid |
| Calcium oxalate stones | Thiazide diuretic or a phosphate-containing preparation |
| struvite stones | antibiotic therapy - since struvite stones are due to infection |
| nutritional management of kidney stones | Depends on the composition of stone high fluid intake |
| possible nutrition changes | Oxalate Restriction Decrease sodium Vitamin C Decrease in animal protein Purine Restriction |
| Oxalate Restriction | foods high in oxalate are spinach, beets, asparagus only 2 moderate meat servings/day |
| surgical management of kidney stones | Cystoscopy Ureteroscopy Percutaneous Nephrolithotomy Lithotripsy Laser Lithotripsy |
| Percutaneous Nephrolithotomy | if stone is in kidney, they can't go through the ureter so you would have to put the needle through the skin |
| indications for lithotripsy or surgical procedure | Stones too large for spontaneous passage Bacteria or symptomatic infection present Causing impaired renal function Persistent pain, nausea, or ileus Patient unable to be treated medically Patient only has one kidney |
| lithotripsy | not an open procedure breaks up stone so its easier to pass can put in a stent to keep it open |
| lithotripsy post op care | Strain all Urine Drains Maintain Fluid Balance Pain Control |
| lithotripsy does not cause | an incision scar |
| lithotripsy will not have an incision scar but will have | lots of pain because of the pounding, typically in flank area only drainage if there's a ureter cath |
| since stones are 80% recurrent, | Infection must be avoided or aggressively treated |
| what to expect with a kidney stone post op pt | May have Foley catheter, Nephrostomy tube, Ureteral stents Urine may be blood tinged but not frank bleeding |
| what should you monitor in kidney stone post op pt | fluid status |
| Nephrostomy Tube is inserted temporarily to | preserve renal function if there is complete obstruction of the ureter |
| what should you never do with a nephrostomy tube | never clamp, watch for kinks |
| if MD orders you to irrigate nephrostomy tube (KNOW) | Strict aseptic technique Don't instill more than 5-10ml of sterile solution (use 10cc flush) Irrigate SLOWLY |
| a pt with nephrostomy tube can also have | a foley because they have two kidneys and 1 could be normal and the other could be obstructed |
Created by:
leh195