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pcc renal
| Question | Answer |
|---|---|
| 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 |
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