Urinary System voluted tubule: 80% of electrolytes Loop of Henle: water Descending loop: water, some sodium, urea, other solutes Ascending loop:chloride, sodium Secretion Other functions of kidney Red blood cell (RBC) production Erythropoietin Blood pressure regulation Renin is secreted Renin activates angiotensinogen to angiotensin Angiotensin I is converted to angiotensin II by ACE Angiotensin II stimulates the release of aldosterone Ureters Join the renal pelvis at the ureteropelvic junction (UPJ) Join the bladder at the ureterovesical junction (UVJ) Bladder Serves as a reservoir for urine Capacity: 600 to 1000 mL Trigone Bladder muscle (detrusor) Urination, micturition, voiding Urethra Extends from bladder neck to external meatus Conduit for urine during voiding Length Female: 12 inches (35 cm) Male: 810 inches (2025 cm) Gerontologic Considerations - Effects of Aging on Urinary System Between ages 30 and 90 Size and weight of kidneys decrease 20% to 30% By seventh decade Loss of 30% to 50% of glomerular function Atherosclerosis accelerates the decrease of renal size with age Physiologic changes Decreased renal blood flow Results in decreased GFR Altered hormonal levels result in Decreased ability to concentrate urine Altered excretion of water, sodium, potassium, and acid Loss of elasticity and muscle support Prostate enlargement Assessment of Urinary System Subjective data Important health information Past health history Medications Surgery or other treatments Functional health patterns Health perceptionhealth management pattern Nutritionalmetabolic pattern Elimination pattern Activityexercise pattern Sleeprest pattern Cognitiveperceptual pattern Selfperceptionselfconcept pattern Rolerelationship pattern Sexualityreproductive pattern Objective data Physical examination Inspection Skin, mouth, face and extremities, abdomen Weight, general state of health Palpation Left kidney rarely palpable Right kidney Bladder Percussion Kidney punch Bladder Auscultation Bell at costovertebral angle (CVA) Diaphragm for bowel sounds

Diagnostic Studies of Urinary System Urine studies Urinalysis First morning void Examine urine within 1 hour Creatinine clearance Collect 24-hour urine specimen Creatinine clearance closely approximates GFR Urodynamics Q&A: A patient is scheduled for cystometrography. Which instructions will the nurse provide to the patient about this procedure?a) The patient will urinate into a specialized toilet to measure the voiding pressure. b) Water will be instilled into the bladder through a catheter to assess bladder tone. Rationale: Cystometrography is an evaluation of bladder tone, sensations of filing, and bladder stability. Water or saline is instilled into the bladder through a urinary catheter.c) The patient will urinate into a container to measure the time and volume of urine excretion.d) The bladder will be filled with contrast media, and fluoroscopic images will be taken during voiding. The nurse is caring for a patient who has just undergone cystoscopy. Which assessment finding necessitates an immediate intervention by the nurse?a) Back painb) Bright red urine Rationale: Bright red urine is not expected after a cystoscopy. Burning on urination, pink-tinged urine, and urinary frequency are expected effects.c) Urinary frequencyd) Burning on urination

Urinary Tract Infection Most common bacterial infection in women At least 20% of women will develop a UTI during their lifetime Bladder and its contents are free of bacteria in majority of healthy persons Minority of healthy individuals have colonizing bacteria in bladder Called asymptomatic bacteriuria and does not justify treatment *Escherichia coli most common pathogen Fungal and parasitic infections can cause UTIs Patients at risk Immunosuppressed Diabetic Having undergone multiple antibiotic courses Have traveled to developing countries Classification of UTI Upper versus lower Upper urinary tract Renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Example Pyelonephritis: inflammation of renal parenchyma and collecting system very serious infection Most commonly caused by bacteria Fungi, protozoa, or viruses can also infect kidneys Lower urinary tract Usually no systemic manifestations Examples Cystitis: inflammation of bladder Urethritis: inflammation of the urethra Complicated versus uncomplicated Uncomplicated UTI Occurs in otherwise normal urinary tract Usually involves only the bladder Complicated UTI Coexists with presence of Obstruction Stones Catheters Diabetes Pregnancy-induced changes Recurrent infection Etiology and Pathophysiology Defense mechanisms to prevent UTI Acidic pH High urea concentration Abundant glycoproteins **UT above urethra normally sterile Alteration of defense mechanisms increases risk of contracting UTI Predisposing factors Factors increasing urinary stasis Examples: BPH, tumor, neurogenic bladder Foreign bodies Examples: catheters, calculi, instrumentation Anatomic factors Examples: obesity, congenital defects, fistula Compromising immune response factors Examples: age, HIV, diabetes Hospital-acquired UTI accounts for 31% of all nosocomial infections Causes Often: E. coli Seldom: Pseudomonas species Catheter-acquired UTIs Bacteria biofilms develop on inner surface of catheter Clinical Manifestations Symptoms related to either bladder storage or bladder emptying Bladder storage Urinary frequency Abnormally frequent (more often than every 2 hours) Urgency Sudden strong desire to void immediately Incontinence Loss or leakage or urine Nocturia Waking up two or more times at night to void Nocturnal enuresis Loss of urine during sleep Bladder emptying Weak stream Hesitancy Difficulty starting the urine stream Intermittency Interruption of urinary stream during voiding Postvoid dribbling Urine loss after completion of voiding Urinary retention Inability to empty urine from bladder Dysuria Difficulty voiding Flank pain, chills, and fever indicate infection of upper tract Pyelonephritis Urosepsis Systemic infection from urologic source Prompt diagnosis/treatment critical Can lead to septic shock and death Septic shock: outcome of unresolved bacteremia involving gram-negative organism In older adults Symptoms often absent Nonlocalized abdominal discomfort rather than dysuria Cognitive impairment possible Fever less likely Diagnostic Studies History and physical examination Dipstick urinalysis Identify presence of nitrites, WBCs, and leukocyte esterase Urine for culture and sensitivity (if indicated) Clean-catch sample preferred Specimen by catheterization or suprapubic needle aspiration more accurate Determine bacteria susceptibility to antibiotics Imaging studies CT urography or ultrasonography when obstruction suspected Collaborative Care - Drug Therapy Antibiotics Selected on empiric therapy or results of sensitivity testing Uncomplicated cystitis Short-term course (1 to 3 days) Complicated UTIs Long-term treatment (7 to 14 days) Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial UTI Inexpensive Taken twice a day E. coli resistance to TMP-SMX Nitrofurantoin (Macrodantin) Given three or four times a day Long-acting preparation (Macrobid) is taken twice daily Ampicillin, amoxicillin, cephalosporins Treat uncomplicated UTI Fluoroquinolones Treat complicated UTIs Example: ciprofloxacin (Cipro) Antifungals Amphotericin or fluconazole UTIs secondary to fungi Urinary analgesic Phenazopyridine (Pyridium) Used in combination with antibiotics Provides soothing effect on urinary tract mucosa Stains urine reddish orange Can be mistaken for blood and may stain underclothing Prophylactic or suppressive antibiotics sometimes administered to patients with repeated UTIs Nursing Management Nursing Assessment Health history Previous UTIs, calculi, stasis, retention, pregnancy, STIs, bladder cancer Antibiotics, anticholinergics, antispasmodics Urologic instrumentation Urinary hygiene Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency Suprapubic/lower back pain, bladder spasms, dysuria, burning sensation on urination Objective data Fever Hematuria, foul-smelling urine, tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP Nursing Diagnoses Impaired urinary elimination Readiness for enhanced self-health management Planning Patient will have Relief from lower urinary tract symptoms Prevention of upper urinary tract involvement Prevention of recurrence Nursing Implementation Health promotion Recognize individuals at risk Debilitated persons Older adults Underlying diseases (HIV, diabetes) Taking immunosuppressive drug or corticosteroids Emptying bladder regularly and completely Evacuating bowel regularly Wiping perineal area front to back Drinking adequate fluids Avoid unnecessary catheterization and early removal of indwelling catheters Aseptic technique must be followed during instrumentation procedures Wash hands before and after contact Wear gloves for care of urinary system Routine and thorough perineal care for all hospitalized patients Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals Acute intervention Adequate fluid intake Dilutes urine, making bladder less irritable Flushes out bacteria before they can colonize Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods Potential bladder irritants Evaluation The patient with a UTI will Experience normal urinary elimination patterns Report relief of bothersome urinary tract symptoms Verbalize knowledge of treatment regimen emphasize importance of taking full medication regime Q&A: The nurse identifies that the patient with the greatest risk for a urinary tract infection isa) A 37-year-old man with renal colic associated with kidney stones.b) A 26-year-old pregnant woman who has a history of urinary tract infections.c) A 69-year-old man who has urinary retention caused by benign prostatic hyperplasia.d) A 72-year-old woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence.

Urinary Tract Calculi 1 to 2 million in United States have nephrolithiasis More common in men Average age at onset: 2055 years Increased incidence White persons Family history of stone formation Previous history Summer months Etiology and pathophysiology Stone formation No single etiology for all cases Factors involved Metabolic Genetic Climate Lifestyle Occupational influences Affected by Urinary pH Solute load Other factors Obstruction with urinary stasis UTI Genetics Types Calcium phosphate Calcium oxalate Uric acid Cystine Struvite (magnesium ammonium phosphate) Clinical manifestations Sudden severe pain due to obstruction Kidney stone dance Mild shock with cool, moist skin Pain moves to lower quadrant of abdomen as stone nears UVJ Testicular versus labial pain Both sexes experience groin pain UTI symptoms Diagnostic studies Noncontrast spiral CT (CT/KUB) Ultrasonography Intravenous pyelorography (IVP) Complete urinalysis to assess for Hematuria Crystalluria Retrieval and analysis of stones Serum calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, BUN, creatinine measurements History Previous episodes Prescribed and OTC medications Dietary supplements Family history Collaborative care Acute attack Treat pain: opioids Infection -antibiotics Obstruction Tamsulosin (Flomax) Terazosin (Hytrin) Teach management of acute episode Drug information monitor urinary pH Strain all urine Ambulation Prevention of further stone development Patient and family history Geographic residence Nutritional assessment Activity patterns Immobilization or dehydration Indications for endourologic stone removal, lithotripsy, or open surgical stone removal include Stones too large for passage Association with bacteriuria Causing impairment in renal function Causing persistent pain, nausea, or paralytic ileus Nursing implementation Teach methods to prevent recurrence Change of lifestyle and dietary habits Adequate fluid intake: to produce approximately 2 L of urine per day Dietary restriction (e.g., purines) Low Na diet Evaluation Maintain free flow of urine with minimal hematuria Report satisfactory pain relief Verbalize understanding of disease process and measures to prevent recurrence

Acute Kidney Injury

Acute kidney injury (AKI), previously known as acute kidney failure, is the term used to encompass the entire range of the syndrome, including a very slight deterioration in kidney function to severe impairment. AKI is characterized by a rapid loss of kidney function. This loss is accompanied by a rise in serum creatinine level and/or a reduction in urine output. The severity of dysfunction can range from a small increase in serum creatinine or reduction in urine output to the development of azotemia (an accumulation of nitrogenous waste products [urea nitrogen, creatinine] in the blood). AKI can develop over hours or days with progressive elevations of blood urea nitrogen (BUN), creatinine, and potassium, with or without a reduction in urine output. Etiology and Pathophysiology Phases of ARF Oliguria Phase Diuretic Phase Recovery Phase ** If a patient does not recover from AKI it can progress to CKD Clinical Manifestations Oliguric phase Urinary changes Urinary output less than 400 mL/day Occurs within 1 to 7 days after injury Lasts 10 to 14 days Urinalysis may show casts, RBCs, WBCs Waste product accumulation Elevated BUN and serum creatinine levels Neurologic disorders Fatigue and difficulty concentrating Seizures, stupor, coma Fluid volume With decreased urine output, fluid retention occurs Neck veins distended Bounding pulse Edema Hypertension Fluid overload can lead to heart failure, pulmonary edema, and pericardial and pleural effusions Metabolic acidosis Serum bicarbonate level decreases Severe acidosis develops Kussmaul respirations Sodium balance Increased excretion of sodium Hyponatremia can lead to cerebral edema Potassium excess Usually asymptomatic ECG changes Diuretic phase Daily urine output is 1 to 3 L May reach 5 L or more Monitor for hyponatremia, hypokalemia, and dehydration Recovery phase May take up to 12 months for kidney function to stabilize Q&A: Which assessment would indicate to the nurse that a patient has oliguria related to an intrarenal acute kidney injury? a) Urinary sodium levels are low.b) The serum creatinine level is normal.c) Oliguria is relieved after fluid replacement. d) Urine testing reveals a specific gravity of 1.010. Rationale: The urine specific gravity in oliguria of intrarenal acute kidney injury will be fixed at 1.010. This value reflects tubular damage with loss of concentrating ability by the kidneys. The serum creatinine level is above normal in oliguria of intrarenal acute kidney injury. Urinary secretion of sodium increases with oliguria of intrarenal acute kidney injury. Prerenal oliguria related to hypovolemia will usually respond to fluid replacement. Diagnostic studies Thorough history Serum creatinine Urinalysis Kidney ultrasonography Renal scan Computed tomography (CT) scan Renal biopsy Contraindicated Magnetic resonance imaging (MRI) Magnetic resonance angiography (MRA) with gadolinium contrast medium Nephrogenic systemic fibrosis Contrast-induced nephropathy (CIN) Collaborative care Primary goals Eliminate the cause Manage signs and symptoms Prevent complications Ensure adequate intravascular volume and cardiac output Closely monitor fluid intake during oliguric phase Hyperkalemia Insulin and sodium bicarbonate Calcium carbonate Sodium polystyrene sulfonate (Kayexalate) Indications for renal replacement therapy (RRT) Volume overload Elevated serum potassium level Metabolic acidosis BUN level higher than 120 mg/dL (43mmol/L) Significant change in mental status Pericarditis, pericardial effusion, or cardiac tamponade Renal replacement therapy (RRT) Peritoneal dialysis (PD) Intermittent hemodialysis (HD) Continuous renal replacement therapy (CRRT) Cannulation of artery and vein Nursing Management Planning The patient with AKI will Completely recover without any loss of kidney function Maintain normal fluid and electrolyte balance Have decreased anxiety Comply with and understand the need for careful follow-up care Nursing implementation Monitor intake and output Monitor electrolyte balance Measure daily weight Replace significant fluid losses Use nephrotoxic drugs sparingly Evaluation The expected outcomes are that the patient with AKI will Regain and maintain normal fluid and electrolyte balance Comply with the treatment regimen Experience no untoward complications Have complete recovery Gerontologic Considerations More susceptible to AKI Polypharmacy Hypotension Diuretic therapy Aminoglycoside therapy Obstructive disorders Surgery Infection

ADDITIONAL ELECTROLYTE DISTURBANCES WITH CRD

Dialysis Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure Treat drug overdoses Begun when patients uremia can no longer be adequately managed conservatively Initiated when GFR (or creatinine clearance) is less than 15 mL/min Dialysis Two methods of dialysis available Peritoneal dialysis (PD) Hemodialysis (HD) ESKD treated with dialysis because There is a lack of donated organs Some patients are physically or mentally unsuitable for transplantation Some patients do not want transplants Osmosis and Diffusion across Semipermeable Membrane Peritoneal Dialysis Peritoneal access is obtained by inserting a catheter through the anterior abdominal wall Technique for catheter placement varies Usually done via surgery Tenckhoff Catheter Waiting period of 7 to 14 days preferable Two to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness Once site healed, patient may shower and pat dry Dialysis Solutions and Cycles Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25% Electrolyte composition similar to that of plasma Solution warmed to body temperature Three phases of PD cycle Inflow (fill) Dwell (equilibration) Drain Called an exchange Inflow Prescribed amount of solution infused through established catheter over about 10 minutes After solution infused, inflow clamp closed to prevent air from entering tubing Dwell Also known as equilibration Diffusion and osmosis occur between patients blood and peritoneal cavity Duration of time varies, depending on method Drain Lasts 15 to 30 minutes May be facilitated by gently massaging abdomen or changing position Complications Exit site infection Peritonitis Hernias Lower back problems Bleeding Pulmonary complications Protein loss Effectiveness and Adaptation Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD Hemodialysis Obtaining vascular access is one of most difficult problems Types of access Arteriovenous fistulas and grafts Temporary vascular access Vascular Access for Hemodialysis Dialyzers Long plastic cartridges that contain thousands of parallel hollow tubes or fibers Fibers are semipermeable membranes Hemodialysis Procedure Two needles placed in fistula or graft One needle is placed to pull blood from the circulation to the HD machine The other needle is used to return the dialyzed blood to the patient Components of Hemodialysis Continual Renal Replacement Therapy (CRRT) Alternative or adjunctive method for treating AKI Means by which uremic toxins and fluids are removed Acid-base status/electrolyte balance adjusted slowly and continuously Often used in hemodynamically unstable patients Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow Specimens may be obtained for evaluation Most common approaches: venovenous Continuous venovenous hemofiltration (CVVH) Continuous venovenous hemodialysis (CVVHD) Q&A: A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patients diet?a) Fatb) Proteinc) Caloriesd) Carbohydrates

Kidney Transplantation Very successful One-year graft survival rate Cadaver transplants: 90% Live donor transplants: 95% Advantages of kidney transplantation over dialysis Reverses many of the pathophysiologic changes associated with renal failure Eliminates dependence on dialysis Less expensive than dialysis after the first year Kidney Transplantation Immunosuppressive Therapy Goals Adequately suppress the immune response Maintain sufficient immunity to prevent overwhelming infection Complications Rejection Acute rejection Occurs days to months after transplantation Chronic rejection Process that occurs over months or years and is irreversible Infection CV Disease Malignancies Recurrance of Renal Disease Steriod-Related Complications Q&A: Six days after kidney transplantation from a deceased donor, a patient develops a temperature of 101.2 F (38.5 C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicatea) Acute rejection, which is not uncommon and is usually reversible.b) Hyperacute rejection, which will necessitate removal of the transplanted kidney.c) An infection of the kidney, which can be treated with IV antibiotics.d) The onset of chronic rejection of the kidney with eventual failure of the kidney.

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