pcc renal
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| 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
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| Color/Clarity of urine | Should be strong yellow to dark yellow, and clear
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| Odor of urine | Slightly aromatic
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| pH of urine | 4.5-8.0
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| Specific Gravity of urine | density of solution compared to density of water
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| specific gravity value | 1.010 – 1.025
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| RBCs in urine | 0 – 2 / high-power field
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| WBCs in urine | 0 – 5 / high-power field
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| Casts in urine | 0, except 1 or 2 hyaline casts / low-power field
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| Crystals in urine | Present
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| Abnormal Substances in urine | protein, glucose, bacteria
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| BUN reference level | Reference Levels = 8-10 mg/dL
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| what does BUN measure? | Measures nitrogen factor of urea = chief end product of protein metabolism
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| where is nitrogen of urea formed? | formed in liver from ammonia
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| nitrogen of urea is excreted by? | kidneys
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| Elevated BUN levels may indicate | a. renal disease
b. reduced renal blood flow
c. urinary tract obstruction
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| Decreased BUN levels may indicate | a. Severe hepatic damage
b. malnutrition
c. overhydration
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| Serum Creatinine Reference levels | 0.6-1.2 mg/DL
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| Creatinine | end product of muscle energy metabolism
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| Creatinine is regulated & excreted by | kidneys
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| Health kidneys | have a fairly creatinine level
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| BUN-to-Creatinine Reference level | 10:1
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| Elevated BUN-to-Creatinine ratio may indicate | hypovolemia
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| Elevated BUN & creatinine may indicate | renal disease
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| Creatinine Clearance measures | volume of blood cleared of indogenous creatinine in one minute
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| Creatine clearance provides | approximation of GFR (which is the Glomerular filtration rate)
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| Elevated levels may indicate | poor hydration, exercise, pregnancy, burns, or hypothyroidism
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| Decreased levels may indicate | severe dehydration, decreased renal blood flow, heart failure
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| 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
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| colorless to pale yellow urine | dilute urine d/t diuretics, alcohol consumptions, diabetes insipidus, glycosuria, excess fluid intake, renal disease
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| yellow to milky white urine | pyuria, infection, vaginal cream
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| bright yellow urine | multiple vitamin preparations
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| 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)
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| blue, blue green urine | dyes, methylene blue, Pseudomonas species organisms, medications (amitriptyline [Amitriptyline HCL], triamterine [Dyrenium])
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| Orange to amber urine | concentrated urine d/t dehydration, fever, bile, excess bilirubin or carotene, medications (pyridium [Phenazopyridium HCL], nitrofurantoin [Furadantin])
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| 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]
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| Cystitis | Inflammation of urinary bladder
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| Nephritis | Inflammation of nephrons
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| Urethritis | Inflammation of ureters
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| Urinary calculi | Stones
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| Routes of getting UTI | Ascending infx, hematogenous spread, or direct extension
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| Contributing factors of UTI | Function of glycosaminoglycan (GAG)
Urethrovesical reflux
Ureterovesical reflux
Uropathogenic bacteria
Shorter urethra in women
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| Function of Glycosaminoglycan | Hydrophilic protein that provides a defense layer btwn bladder and urine
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| Certain agents interfere with protective qualities of Glycosaminoglycan | Saccharin, Aspartame (sugar substitute,Tryptophan (Turkey)
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| 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
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| Ureterovesical Reflux (Vesicoureteral) | Backward flow of urine & bacteria from bladder into the ureters d/t impaired ureterovesical valve or ureteral abnormalities
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| Uropathogenic Bacteria | Female
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| Shortened Urethra in Women | Provides little resistance to movement of bacteria
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| Bladder | Common site of nosocomial infx
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| Lower UTIs | Cystitis(bladder), Prostatitis(prostate),Urethritis(urethra)
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| Upper UTIs | Pyelonephritis(acute & chronic - kidneys),Interstitial nephritis, Renal abscess & peroneal abscess
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| 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
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| 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
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| Calculi (stones) occur in | urinary tract or kidney
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| Causes of Calculi | ↑ calcium & uric acid urine concentration,Dehydration, infx, stasis, immobility,Polycystic disease, horseshoe kidneys, strictures, May be unknown
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| Manifestations of Calculi | Depend upon location & presence of obstruction or infx,Pain & hematuria
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| Diagnosis of Calculi | H&P,X-ray,Blood chemistries & stone analysis
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| Nursing intervention with passing of calculi | Strain all urine & save stones
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| Major Goals with UTI pt | Relief of pain & discomfort
Increased knowledge of preventive measures
Treatment modalities
Absence of complications
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| 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
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| Urinary Tract irritants | coffee, tea, citrus, spices, cola & alcohol
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| Meds to take for UTI | antibiotics, analgesics, & antispasmodics
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| 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
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| Oxalate-containing foods | spinach, strawberries, rhubarb, tea, peanuts, Wheat bran
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| Pts with kidney stones need to call physician with first sign of | UTI
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| Urinary retention | Inability of bladder to empty completely; inability to void even with urge
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| Residual urine | amount of urine left in bladder after voiding
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| 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
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| Chronic urinary retention may lead to | overflow incontinence;
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| urinary retention is especially seen with | peroneal & rectal surgeries & general anesthesia
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| What questions should be asked? | Time & amt of last void?, Voiding small amts frequently?, Having dribbling?, Pain or discomfort?,Any s/sxs of UTI
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| 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,
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| 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
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| Ways to Relax sphincters | Sitz bath or shower, Warm compresses to perineum
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| 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
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| 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
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| Risk factors for urinary incontinence continued | morbid obesity, cognitive disturbances: dementia, Parkinson's disease, medications: diuretics, sedatives, hypnotics, opiods, caregiver or toilet unavailable
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| 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
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| 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
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| Neurogenic Bladder results from | lesions of nervous system
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| Neurogenic Bladder Leads to | urinary incontinence
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| 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
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| 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
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| Neurogenic Bladder Assesment & diagnostics | Measure I&O
Assess for residual urine
Assess sensory awareness & degree of motor control
Urinalysis
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| Management of Neurogenic bladder Therapy | pharmacological, correct surgery,catherization
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| Pharmacologic Therapy with Neurogenic bladder | Parasympathomimetics to increase contraction of detrusor muscle Ex: Urecholine
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| Corrective Surgery with Neurogenic bladder | Bladder neck contractures, Vesicoureteral reflux,Urinary diversion
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| Catheterization with Neurogenic bladder | Continuous, intermittent, or self-catheterization; Condom catheters
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| Urinary Diversion | Diverts urine from bladder to new exit site
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| Types of Urinary Diversion | Cutaneous urinary diversion, Continent urinary diversion
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| Reasons for Urinary Diversion | Cancer of bladder, Trauma, Radiation injury to bladder, Fistula, Chronic or intractable cystitis, Neurogenic bladder, Last resort for incontinence
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| Cutaneous Urinary Diversion-Preoperative Interventions |
Relieve Anxiety
Ensure adequate nutrition
May require prophylactic antibiotics
Preoperative hydration
Explain surgery & its effects
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| 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
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| Possible post-op Cutaneous Urinary Diversion complications | Infx, Urinary leakage, Dehiscence, Ureteral obstruction
Ileus, Gangrene of stoma
Hyperchloremic acidosis
Small bowel obstruction
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| Postoperative Cutaneous Urinary Diversion Interventions | Monitor for complications, pain management, PCA or scheduled analgesics, Stoma & skin care,Assess stoma q 4 hrs
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| Assess skin for | Signs of irritation or bleeding,Encrustation or skin irritation, Infx
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| assess stoma after Cutaneous Urinary Diversion | q 4 hours; Irrigate with 5 – 10 mL sterile NS if not draining
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| Immediately post-op Cutaneous Urinary Diversion | monitor UOP q1hr
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| sudden decrease in UOP & increase in drainage may indicate | leakage
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| UOP <30 mL may indicate | dehydration or obstruction
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| Complications of cutaneous urinary diversion | pneumonia, atelectasis, peritonitis d/t urinary leakage
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| s/sx of infection | assess bowel sound for (ileum ischemia & necrosis), fever, leukocytes, pain, distention,
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| Post Cutaneous Urinary Diversions want to maintain urine pH below | 6.5
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| Interventions to maintain urine pH | administer ascorbic acid po
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| If foul odor is present in urine | catheterize stoma for C&S, call physician
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| Post-Cutaneous Urinary Diversion encourage fluids because | decrease amount of normal post-op mucus in urine(can cause infx & obstruction), teach to decrease anxiety
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| Choose ostomy appliance based on | stoma location, manual dexterity, body build, personal preference, activity level, visual function, economic resource
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| Teaching self care post-cutaneous urinary diversion | change appliance
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| Need to change urinary diversion device | before system leaks, at convenient time, use skin barrier, but no tape or patches, avoid moisturizing soaps
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| 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
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| Managing ostomy appliance | empty via drain valve when 1/3 full, may use an adapter & leg bag to promote sleep
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| 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
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| Teaching self care post-cutaneous urinary diversion | change appliance
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| Need to change urinary diversion device | before system leaks, at convenient time, use skin barrier, but no tape or patches, avoid moisturizing soaps
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| 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
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| Managing ostomy appliance | empty via drain valve when 1/3 full, may use an adapter & leg bag to promote sleep
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| 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
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| 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
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| Post-op interventions-Continuing Care- Urinary Diversion | encourage follow-up to assess self-management
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| 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
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| Potential long term complications of urinary diversion | ureteral obstruction, stenosis, hernias, decreased renal function
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| 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
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| Why must the Indiana pouch be emptied at regular intervals | prevents absorption of waste products, reflux & UTI
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| Irrigate cecostomy tube | 2-3 times daily post-op to prevent occlusion from mucus
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| Hemodialysis | prevents death but is not a cure; Acts as artificial kidney to filter and discrete toxic substances and remove excess water
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| 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
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| Routes for hemodialysis | central venous catheter, AV fistula, AV graft
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| AV fistula | surgically joins an artery to vein(either side to side or end to side)
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| AV graft | subq interposing graft material between an artery and vein
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| 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)
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| Thrill | you can feel vibration of blood going through access site
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| Bruit | is a swishing sound heard over fistula site
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| Activity Instructions for hemodialysis pts | (routine ROM is encouraged, but no activity that would occlude or compress extremity)
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| 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)
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| Goal of Peritoneal Dialysis | remove toxic substances & metabolic wastes , Re-establish normal F&E balance
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| AIPD | common routine: 10 min of infusion, 30 min of dwell time, 20 min for drain time
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| CAPD | 4-5 times/day, 24/7, @ intervals scheduled throughout day
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| CCPD | uses cycler machine for exchanges during night, disconnects from cycler in morning, dialysate left in abdominal cavity to dwell during the day
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| Indications for use of peritoneal dialysis | hemodynamically unstable, diabetes & CV disease, older adults(more flexibility), severe HTN, HF, pulmonary edema
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| Contraindications for peritoneal dialysis | chronic back ache or disc disease, adhesions from previous surgeries, diverticulitis, severe arthritis or poor hand strength
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| Peritoneal Dialysis-Intra-abdominal catheter | peritoneum-surgically placed in the abdominal cavity (nondominant side) for infusion of dialysate)
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| Peritoneal Dialysis-Intra-abdominal catheter | peritoneum-surgically placed in the abdominal cavity (nondominant side) for infusion of dialysate)
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| 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
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| Acute complications of peritoneal dialysis | peritonitis, leakage, bleeding
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| Long Term complications of peritoneal dialysis | hypertriglyceridemia, abdominal hernias, hemorrhoids, low back pain, clots in peritoneal catheter, constipation
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| 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
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| UTI Dietary Management | drink liberal amounts of fluid daily, avoid urinary tract irritants such as coffee, tea, colas, alcohol
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| 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)
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| 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
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| Relieve Discomfort Pre-op Prostatectomy | bed rest, analgesic agents, catheter if indicated
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| 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
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| Prepare Client for prostatectomy | anti-embolism stockings, enema at home or in hospital
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| What medications need to be D/C before prostatectomy? How long before? | aspirin, NSAIDS, & platelet inhibitors 10-14 days prior
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| Prostatectomy complications | hemorrhage, infx, DVT, PE, Catheter obstruction, Urinary incontinence, sexual dysfunction
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| Indications of hemorrhage | bright red bleeding with increased viscosity & clots
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| Interventions Hemorrhage | may require fluid & blood components, closely monitor VS
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| 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
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| 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
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| Relieve Discomfort Pre-op Prostatectomy | bed rest, analgesic agents, catheter if indicated
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| 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
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| Prepare Client for prostatectomy | anti-embolism stockings, enema at home or in hospital
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| What medications need to be D/C before prostatectomy? How long before? | aspirin, NSAIDS, & platelet inhibitors 10-14 days prior
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| Prostatectomy complications | hemorrhage, infx, DVT, PE, Catheter obstruction, Urinary incontinence, sexual dysfunction
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| Indications of hemorrhage | bright red bleeding with increased viscosity & clots
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| Interventions Hemorrhage | may require fluid & blood components, closely monitor VS
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| 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
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| DVT/PE interventions | anti-embolism stockings, early ambulation, may require heparin or Lovenox
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| Catheter Obstruction interventions | assess for bladder distention, examine drainage bag, dressings, & incision for bleeding
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| 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
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| Sexual Dysfunction interventions | reassure that libido will return, fatigue will decrease, may require meds, implants or negative pressure devices
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| 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
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| 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
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| 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
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| Interventions for bladder spasms | warm compressess, urispa or ditropan
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| Notify physician if post-prostatectomy pain is | not relieved by prescribed analgesics
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| Irrigate prostatectomy | as ordered to prevent obstruction, monitor irrigant output closely
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| Pre-op Interventions-hysterectomy | discontinue certain medications, rule out pregnancy, prophylactic antibiotics, thromboembolic prevention,
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| Discontinue what medications before hysterectomy | anticoagulants, NSAIDS, Aspirin, Vit E
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| 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
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| Post-Op interventions hysterectomy | relieve anxiety (allow to verbalize concerns), improve body image (talk about fertility & sexuality)
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| Complications of Hysterectomy | hemorrhage, DVT/PE, bladder dysfunction
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| Hemorrhage Interventions Hysterectomy | count perineal pads used, assess saturation of pads & dressings, monitor VS
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| 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
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| 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
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| Home Care Teaching Post-Hysterectomy | known limitations/restrictions, assess incision daily, may have slight bloody discharge for a few days(report any additional bleeding),
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| 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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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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