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pcc renal

QuestionAnswer
Urinalysis 1. Screen pt’s urine for renal or urinary tract disease 2. Helps detect metabolic or systemic disease unrelated to renal disorders 3. Detect presence of drugs
Color/Clarity of urine Should be strong yellow to dark yellow, and clear
Odor of urine Slightly aromatic
pH of urine 4.5-8.0
Specific Gravity of urine density of solution compared to density of water
specific gravity value 1.010 – 1.025
RBCs in urine 0 – 2 / high-power field
WBCs in urine 0 – 5 / high-power field
Casts in urine 0, except 1 or 2 hyaline casts / low-power field
Crystals in urine Present
Abnormal Substances in urine protein, glucose, bacteria
BUN reference level Reference Levels = 8-10 mg/dL
what does BUN measure? Measures nitrogen factor of urea = chief end product of protein metabolism
where is nitrogen of urea formed? formed in liver from ammonia
nitrogen of urea is excreted by? kidneys
Elevated BUN levels may indicate a. renal disease b. reduced renal blood flow c. urinary tract obstruction
Decreased BUN levels may indicate a. Severe hepatic damage b. malnutrition c. overhydration
Serum Creatinine Reference levels 0.6-1.2 mg/DL
Creatinine end product of muscle energy metabolism
Creatinine is regulated & excreted by kidneys
Health kidneys have a fairly creatinine level
BUN-to-Creatinine Reference level 10:1
Elevated BUN-to-Creatinine ratio may indicate hypovolemia
Elevated BUN & creatinine may indicate renal disease
Creatinine Clearance measures volume of blood cleared of indogenous creatinine in one minute
Creatine clearance provides approximation of GFR (which is the Glomerular filtration rate)
Elevated levels may indicate poor hydration, exercise, pregnancy, burns, or hypothyroidism
Decreased levels may indicate severe dehydration, decreased renal blood flow, heart failure
MRI Pre-Test Teaching = 1.No alcohol, caffeine, or smoking 2 hrs prior 2.No food 1 hour prior 3.No iron supplements – they may interfere with imaging
colorless to pale yellow urine dilute urine d/t diuretics, alcohol consumptions, diabetes insipidus, glycosuria, excess fluid intake, renal disease
yellow to milky white urine pyuria, infection, vaginal cream
bright yellow urine multiple vitamin preparations
pink to red urine hemoglobin breakdown, red blood cells, gross blood, menses, bladder or prostate surgery, beets, blackberries, medications (phenytoin [Dilantin], rifampin [Rifadin], phenothiazine [Mellaril], cascara [Sagrada], senna products)
blue, blue green urine dyes, methylene blue, Pseudomonas species organisms, medications (amitriptyline [Amitriptyline HCL], triamterine [Dyrenium])
Orange to amber urine concentrated urine d/t dehydration, fever, bile, excess bilirubin or carotene, medications (pyridium [Phenazopyridium HCL], nitrofurantoin [Furadantin])
Brown to black urine old red blood cells, urobilinogen, bilirubin, melanin, porphyrin, extremely concentrated urine d/t dehyration, medications (cascara, metronidazole [Flagy], iron preparations, quinine [Quinine Sulfate], senna products, methyldopa [Aldomet], nitrofurantoin]
Cystitis Inflammation of urinary bladder
Nephritis Inflammation of nephrons
Urethritis Inflammation of ureters
Urinary calculi Stones
Routes of getting UTI Ascending infx, hematogenous spread, or direct extension
Contributing factors of UTI Function of glycosaminoglycan (GAG) Urethrovesical reflux Ureterovesical reflux Uropathogenic bacteria Shorter urethra in women
Function of Glycosaminoglycan Hydrophilic protein that provides a defense layer btwn bladder and urine
Certain agents interfere with protective qualities of Glycosaminoglycan Saccharin, Aspartame (sugar substitute,Tryptophan (Turkey)
Urethrovesical Reflux Backward flow of urine from urethra into bladder Ex: Sneeze → ↑ bladder pressure →forces urine from bladder into urethra →pressure returns to normal →urine flows back into bladder with bacteria
Ureterovesical Reflux (Vesicoureteral) Backward flow of urine & bacteria from bladder into the ureters d/t impaired ureterovesical valve or ureteral abnormalities
Uropathogenic Bacteria Female
Shortened Urethra in Women Provides little resistance to movement of bacteria
Bladder Common site of nosocomial infx
Lower UTIs Cystitis(bladder), Prostatitis(prostate),Urethritis(urethra)
Upper UTIs Pyelonephritis(acute & chronic - kidneys),Interstitial nephritis, Renal abscess & peroneal abscess
Assessment of pt with UTI Hx of Symptoms Voiding patterns Association of symptoms with sexual intercourse Contraceptive practices Personal hygiene Gerontologic considerations Assess urine, urinalysis, and urine cultures Other diagnostic tests
History of symptoms of UTI 1. About half of patients are asyptomatic 2. Pain & burning upon urination &/or frequency 3. nocturia 4. incontinence 5. Suprapubic, pelvic, or back pain 6. Hematuria or change in urine or urinary pattern
Calculi (stones) occur in urinary tract or kidney
Causes of Calculi ↑ calcium & uric acid urine concentration,Dehydration, infx, stasis, immobility,Polycystic disease, horseshoe kidneys, strictures, May be unknown
Manifestations of Calculi Depend upon location & presence of obstruction or infx,Pain & hematuria
Diagnosis of Calculi H&P,X-ray,Blood chemistries & stone analysis
Nursing intervention with passing of calculi Strain all urine & save stones
Major Goals with UTI pt Relief of pain & discomfort Increased knowledge of preventive measures Treatment modalities Absence of complications
Prevention of UTI Avoid indwelling catheters,Proper care of catheters, Teach & encourage correct personal hygiene;Take meds as prescribed,Apply heat to perineum to relieve pain & spasm,Increase fluid intake,Avoid urinary tract irritants,Frequent voiding
Urinary Tract irritants coffee, tea, citrus, spices, cola & alcohol
Meds to take for UTI antibiotics, analgesics, & antispasmodics
Preventing Kidney Stones Restricted protein intake, Decreased calcium intake, Avoid oxalate-containing foods, drink fluids q 1-2 hrs, drink 2 glasses at bedtime and sips when waking up, avoid excessive sweating & dehydration
Oxalate-containing foods spinach, strawberries, rhubarb, tea, peanuts, Wheat bran
Pts with kidney stones need to call physician with first sign of UTI
Urinary retention Inability of bladder to empty completely; inability to void even with urge
Residual urine amount of urine left in bladder after voiding
Causes of urinary retention Age (50 to 100 mL) in adults > age 60 d/t ↓ detrusor muscle activity, Diabetes, Prostate enlargement, Pregnancy, Neurologic disorders,Post-op, Medications
Chronic urinary retention may lead to overflow incontinence;
urinary retention is especially seen with peroneal & rectal surgeries & general anesthesia
What questions should be asked? Time & amt of last void?, Voiding small amts frequently?, Having dribbling?, Pain or discomfort?,Any s/sxs of UTI
Nursing Measures to Promote Voiding: Provide Privacy, Appropriate positioning / body alignment,Assist to bathroom or BSC, Allow men to stand at the side of the bed with a urinal if appropriate, Turn on water faucet or dip the client’s hand in warm water,
Nursing measures to promote voiding contiued Stroke abd or inner thigh or tap above pubic area, Offer encouragement / support, May need to catheterize if necessary
Ways to Relax sphincters Sitz bath or shower, Warm compresses to perineum
Urinary Incontinence is Under-diagnosed / underreported problem, Can significantly impact quality of life, May ↓ independence, May lead to compromise of upper urinary system, Not a normal consequence of aging
Risk factors for urinary incontinence pregnancy: vaginal delivery, episiotomy, meopause, genitourinary surgery, pelvic muscle weakness, incompetent urethra d/t trauma or sphincter relaxation, immobility, high-impact exercise, diabetes mellitus, stroke, age-related changes in the urinary tract
Risk factors for urinary incontinence continued morbid obesity, cognitive disturbances: dementia, Parkinson's disease, medications: diuretics, sedatives, hypnotics, opiods, caregiver or toilet unavailable
Causes of incontinence Stress D/t sneezing, coughing, or position change Urge Loss of urine associated with strong urge to void Functional Ex: Alzheimer’s / dementia Iatrogenic D/t extrinsic med factors, ex: meds Mixed incontinence Combination
Patient Teaching with incontinence Not inevitable & is treatable Management takes time provide encouragement & support Develop & use voiding log or diary Behavioral interventions See Chart 45-8 Medication teaching related to pharm therapy Strategies for Promoting Continence
Neurogenic Bladder results from lesions of nervous system
Neurogenic Bladder Leads to urinary incontinence
Spastic (or reflex) Bladder (Neurogenic Bladder Type) d/t spinal cord lesion above voiding reflex arc; Loss of conscious sensation & cerebral motor control; Empties on reflex
Flaccid Bladder (Type of Neurogenic Bladder) d/t lower motor neuron lesion; Found in trauma & DM; Overflow incontinence occurs from over distension; Bladder muscle does not contract in time
Neurogenic Bladder Assesment & diagnostics Measure I&O Assess for residual urine Assess sensory awareness & degree of motor control Urinalysis
Management of Neurogenic bladder Therapy pharmacological, correct surgery,catherization
Pharmacologic Therapy with Neurogenic bladder Parasympathomimetics to increase contraction of detrusor muscle Ex: Urecholine
Corrective Surgery with Neurogenic bladder Bladder neck contractures, Vesicoureteral reflux,Urinary diversion
Catheterization with Neurogenic bladder Continuous, intermittent, or self-catheterization; Condom catheters
Urinary Diversion Diverts urine from bladder to new exit site
Types of Urinary Diversion Cutaneous urinary diversion, Continent urinary diversion
Reasons for Urinary Diversion Cancer of bladder, Trauma, Radiation injury to bladder, Fistula, Chronic or intractable cystitis, Neurogenic bladder, Last resort for incontinence
Cutaneous Urinary Diversion-Preoperative Interventions Relieve Anxiety Ensure adequate nutrition May require prophylactic antibiotics Preoperative hydration Explain surgery & its effects
Cutaneous Urinary Diversion Stents placed in ureters for 1-3 week, Prevent occlusion d/t edema, JP tubes inserted to prevent accumulated fluid, Skin barrier & urinary drainage bag placed
Possible post-op Cutaneous Urinary Diversion complications Infx, Urinary leakage, Dehiscence, Ureteral obstruction Ileus, Gangrene of stoma Hyperchloremic acidosis Small bowel obstruction
Postoperative Cutaneous Urinary Diversion Interventions Monitor for complications, pain management, PCA or scheduled analgesics, Stoma & skin care,Assess stoma q 4 hrs
Assess skin for Signs of irritation or bleeding,Encrustation or skin irritation, Infx
assess stoma after Cutaneous Urinary Diversion q 4 hours; Irrigate with 5 – 10 mL sterile NS if not draining
Immediately post-op Cutaneous Urinary Diversion monitor UOP q1hr
sudden decrease in UOP & increase in drainage may indicate leakage
UOP <30 mL may indicate dehydration or obstruction
Complications of cutaneous urinary diversion pneumonia, atelectasis, peritonitis d/t urinary leakage
s/sx of infection assess bowel sound for (ileum ischemia & necrosis), fever, leukocytes, pain, distention,
Post Cutaneous Urinary Diversions want to maintain urine pH below 6.5
Interventions to maintain urine pH administer ascorbic acid po
If foul odor is present in urine catheterize stoma for C&S, call physician
Post-Cutaneous Urinary Diversion encourage fluids because decrease amount of normal post-op mucus in urine(can cause infx & obstruction), teach to decrease anxiety
Choose ostomy appliance based on stoma location, manual dexterity, body build, personal preference, activity level, visual function, economic resource
Teaching self care post-cutaneous urinary diversion change appliance
Need to change urinary diversion device before system leaks, at convenient time, use skin barrier, but no tape or patches, avoid moisturizing soaps
Ways to control odor post-urinary diversion avoid foods that increase odor (ex. Asparagus, cheese or eggs), may use liquid deodorizer or diluted white vinegar, do not use aspirin
Managing ostomy appliance empty via drain valve when 1/3 full, may use an adapter & leg bag to promote sleep
Cleaning ostomy steps rinse with warm water->soak in 3:1 solution of water & vinegar or deodorizer for 30 min->rinse with tepid water->air dry away from direct sunlight
Teaching self care post-cutaneous urinary diversion change appliance
Need to change urinary diversion device before system leaks, at convenient time, use skin barrier, but no tape or patches, avoid moisturizing soaps
Ways to control odor post-urinary diversion avoid foods that increase odor (ex. Asparagus, cheese or eggs), may use liquid deodorizer or diluted white vinegar, do not use aspirin
Managing ostomy appliance empty via drain valve when 1/3 full, may use an adapter & leg bag to promote sleep
Cleaning an ostomy rinse with warm water->soak in 3:1 solution of water & vinegar or deodorizer for 30 min->rinse with tepid water->air dry away from direct sunlight
Need to address sexuality issues with pts with urinary diversions encourage pt and partner to share their feelings , Encourage counseling and may need to explore alternate ways of expressing sexuality
Post-op interventions-Continuing Care- Urinary Diversion encourage follow-up to assess self-management
Home Care Nurse post-op urinary diversion assess pt & family coping abilities, as stoma changes post-op determine any changes needed, provide info on additional resources, assess for potential long term complications
Potential long term complications of urinary diversion ureteral obstruction, stenosis, hernias, decreased renal function
Indiana Pouch continent ileal urinary reservoir, uses segment of ileum & cecum, emptied via catheter, must be emptied at regular intervals, monitor all additional drains for patency & drainage
Why must the Indiana pouch be emptied at regular intervals prevents absorption of waste products, reflux & UTI
Irrigate cecostomy tube 2-3 times daily post-op to prevent occlusion from mucus
Hemodialysis prevents death but is not a cure; Acts as artificial kidney to filter and discrete toxic substances and remove excess water
How hemodialysis works Blood passes through a dialysier, hollw-fiber devices, porous and act as a semipermeable membrane allowing toxins, fluid and electrolytes to pass through
Routes for hemodialysis central venous catheter, AV fistula, AV graft
AV fistula surgically joins an artery to vein(either side to side or end to side)
AV graft subq interposing graft material between an artery and vein
Vascular Access Device Interventions protect vascular access, assess for patency & sx of potential infx, do NOT use for blood pressure or blood draws, palpate for thrill, auscultate for bruit, check color, monitor fluid balance indicators & monitor IV therapy carefully(accurate I&O)
Thrill you can feel vibration of blood going through access site
Bruit is a swishing sound heard over fistula site
Activity Instructions for hemodialysis pts (routine ROM is encouraged, but no activity that would occlude or compress extremity)
Vascular access device interventions Assess for uremia & electrolyte imbalance (regularly check lab data), monitor cardiac & resp status carefully (assess distal pulses), Instruct Client (routine ROM is encouraged, but no activity that would occlude or compress extremity)
Goal of Peritoneal Dialysis remove toxic substances & metabolic wastes , Re-establish normal F&E balance
AIPD common routine: 10 min of infusion, 30 min of dwell time, 20 min for drain time
CAPD 4-5 times/day, 24/7, @ intervals scheduled throughout day
CCPD uses cycler machine for exchanges during night, disconnects from cycler in morning, dialysate left in abdominal cavity to dwell during the day
Indications for use of peritoneal dialysis hemodynamically unstable, diabetes & CV disease, older adults(more flexibility), severe HTN, HF, pulmonary edema
Contraindications for peritoneal dialysis chronic back ache or disc disease, adhesions from previous surgeries, diverticulitis, severe arthritis or poor hand strength
Peritoneal Dialysis-Intra-abdominal catheter peritoneum-surgically placed in the abdominal cavity (nondominant side) for infusion of dialysate)
Peritoneal Dialysis-Intra-abdominal catheter peritoneum-surgically placed in the abdominal cavity (nondominant side) for infusion of dialysate)
Equipment involved in peritoneal dialysis silicone catheter with radiopaque strip, sterile dialysate(warmed to body temp-dry heat recommended), drainage bag, depending on type may need either an automated or a continuous cycling machine
Acute complications of peritoneal dialysis peritonitis, leakage, bleeding
Long Term complications of peritoneal dialysis hypertriglyceridemia, abdominal hernias, hemorrhoids, low back pain, clots in peritoneal catheter, constipation
Inventions for peritoneal dialysis baseline VS, wt, & serum electrolytes, aseptic technique, assess for resp distress, pain/discomfort, maintain accurate inflow & outflow records, # of exchanges & frequency are determined by monthly lab values & presence of uremic symptoms
UTI Dietary Management drink liberal amounts of fluid daily, avoid urinary tract irritants such as coffee, tea, colas, alcohol
Renal Calculi dietary management restrict protein intake to 60 g/day, reduce table salt & high sodium foods to 3-4 g/day, avoid oxalate containing foods(spinach, strawberries, rhubarb, tea, peanuts, wheat bran), drink water every 1 to 2 hours during day (sips at night time awakening)
Preoperative Interventions (Prostatectomy) reduce anxiety,:be sensitive to potentially embarassing & culturally charged issues, establish a professional trusting relationship, provide privacy, allow pt to verbalize concerns, provide & reinforce information
Relieve Discomfort Pre-op Prostatectomy bed rest, analgesic agents, catheter if indicated
Provide instructions pre-op prostatectomy explain procedure & what to expect, answer any questions, instruct to D/C all aspirin, NSAIDS, & platelet inhibitor 10-14 days prior
Prepare Client for prostatectomy anti-embolism stockings, enema at home or in hospital
What medications need to be D/C before prostatectomy? How long before? aspirin, NSAIDS, & platelet inhibitors 10-14 days prior
Prostatectomy complications hemorrhage, infx, DVT, PE, Catheter obstruction, Urinary incontinence, sexual dysfunction
Indications of hemorrhage bright red bleeding with increased viscosity & clots
Interventions Hemorrhage may require fluid & blood components, closely monitor VS
Interventions to prevent hemorrhage careful aseptic dressing changes, avoid rectal thermometers, tubes & enemas, sitz baths & heat lamps promote healing, antibiotics if ordered, teach client to report s/sx of infx
Preoperative Interventions (Prostatectomy) reduce anxiety,:be sensitive to potentially embarrassing & culturally charged issues, establish a professional trusting relationship, provide privacy, allow pt to verbalize concerns, provide & reinforce information
Relieve Discomfort Pre-op Prostatectomy bed rest, analgesic agents, catheter if indicated
Provide instructions pre-op prostatectomy explain procedure & what to expect, answer any questions, instruct to D/C all aspirin, NSAIDS, & platelet inhibitor 10-14 days prior
Prepare Client for prostatectomy anti-embolism stockings, enema at home or in hospital
What medications need to be D/C before prostatectomy? How long before? aspirin, NSAIDS, & platelet inhibitors 10-14 days prior
Prostatectomy complications hemorrhage, infx, DVT, PE, Catheter obstruction, Urinary incontinence, sexual dysfunction
Indications of hemorrhage bright red bleeding with increased viscosity & clots
Interventions Hemorrhage may require fluid & blood components, closely monitor VS
Interventions to prevent hemorrhage careful aseptic dressing changes, avoid rectal thermometers, tubes & enemas, sitz baths & heat lamps promote healing, antibiotics if ordered, teach client to report s/sx of infx
DVT/PE interventions anti-embolism stockings, early ambulation, may require heparin or Lovenox
Catheter Obstruction interventions assess for bladder distention, examine drainage bag, dressings, & incision for bleeding
Urinary Incontinence interventions occurs in 80-95% of pts, teach pt to increase voiding frequency, avoid positions that encourage voiding, decrease intake prior to activities, and pelvic floor exercises
Sexual Dysfunction interventions reassure that libido will return, fatigue will decrease, may require meds, implants or negative pressure devices
Home Care post-prostatectomy urine may be cloudy for several weeks, avoid inducing valsalva effects, avoid long trips & strenuous exercise, spicy foods, alcohol, & coffee may induce bladder discomfort, immediately report any s/sx of complications
Post-Op interventions Prostatectomy closely monitor UIP & amt of irrigation used, monitor for electrolyte imbalances, monitor for increased BP, confusion or rep. distress, activity, bladder spasms, Monitor tubing for patency, analgesics as prescribed, prune juice & stool softeners
Activity Post-Op Prostatectomy Post-op Day 0-sit & dangle legs, Post-op day 1 – assist with ambulation, after that-encourage walking but not sitting for long periods of time
Interventions for bladder spasms warm compressess, urispa or ditropan
Notify physician if post-prostatectomy pain is not relieved by prescribed analgesics
Irrigate prostatectomy as ordered to prevent obstruction, monitor irrigant output closely
Pre-op Interventions-hysterectomy discontinue certain medications, rule out pregnancy, prophylactic antibiotics, thromboembolic prevention,
Discontinue what medications before hysterectomy anticoagulants, NSAIDS, Aspirin, Vit E
Pain Relief Post-op hysterectomy analgesics as prescribed, may need to limit intake for 1-2 days, may require rectal tube or heat to abd, permit additional fluids & soft diet when BS & peristalsis return, encourage early ambulation
Post-Op interventions hysterectomy relieve anxiety (allow to verbalize concerns), improve body image (talk about fertility & sexuality)
Complications of Hysterectomy hemorrhage, DVT/PE, bladder dysfunction
Hemorrhage Interventions Hysterectomy count perineal pads used, assess saturation of pads & dressings, monitor VS
DVT/PE Interventions with Hysterectomy anti-embolism stockings, change positions frequently, exercise legs and feet while in bed, early ambulation, avoid pressure behind knees & sitting for long periods of time
Bladder Dysfunction Interventions with Hysterectomy remove catheter when pt begins to ambulate, closely monitor UOP, assess for abd distention, encourage voiding(ex. Pouring warm water over perineum), may require re-catherization
Home Care Teaching Post-Hysterectomy known limitations/restrictions, assess incision daily, may have slight bloody discharge for a few days(report any additional bleeding),
Home Care teaching post-hysterectomy (continued) do not sit for long periods of time, showers preferred over baths, avoid straining, lifts, intercourse & driving until surgeon permits, immediately report s/sx of complications
Created by: 747795147