1. Students to review and study renal anatomy and physiology prior to lecture. Functions of the kidney:

Urine Formation Filtration – kidneys filter waste products from the blood, return needed

components through reabsorption Regulation: Water balance, acid base balance, red blood cell production Excretory: removal of potentially toxic end products from diet and drugs Synthesis of hormones:

Renin- regulates BP Activated vitamin D

• Ureters 12 to 18” long, extend from renal pelvis of kidney to bladder, backflow prevention

• Bladder- elastic sac, stores and excretes urine • Detrusor muscle

2. Describe assessment methods for renal system. Assessment of urinary system: Demographic information, such as age, gender, race, and ethnicity, is important to consider as nonmodifiable risk factors in the patient with any kidney or urinary problem. A sudden onset of hypertension in patients older than 50 years suggests possible kidney disease. Clinical changes with adult polycystic kidney disease typically occur in patients in their 40s or 50s. In men older than 50 years, altered urinary patterns accompany prostate disease. Anatomic gender differences make some disorders worse or more common. For example, men rarely have urinary tract infections unless there are abnormalities, such as ureteral reflux or prostatic enlargement. Women have a shorter urethra and more commonly develop cystitis (bladder infection) because bacteria pass more readily into the bladder. Ask the patient about any previous kidney or urologic problems, including tumors, infections, stones, or urologic surgery. A history of any chronic health problems, especially diabetes mellitus or hypertension, increases the risk for development of kidney disease because these disorders damage kidney blood vessels. Ask the patient about chemical exposures at the workplace or with hobbies. Exposure to hydrocarbons (e.g., gasoline, oil), heavy metals (especially mercury and lead), and some gases (e.g., chlorine, toluene) can impair kidney function. Use this opportunity to teach patients who come into contact with chemicals at work or during leisure time activities to avoid direct skin or mucous membrane contact with

these chemicals. Use of heroin, cocaine, methamphetamine, ecstasy, and volatile solvents (inhalants) has also been associated with kidney damage. Ask the patient with known or suspected kidney or urologic disorders about his or her usual diet and any recent changes in the diet. Note any excessive intake or omission of certain food categories. Ask about food and fluid intake. Assess how much and what types of fluids the patient drinks daily, especially fluids with a high calorie or caffeine content. Use this opportunity to teach the patient the importance of drinking about 3 L of fluid daily (if another medical problem does not require fluid restriction) to prevent dehydration and cystitis. Medication History Identify all of the patient's prescription drugs because many can impair kidney function. Ask about the duration of drug use and whether there have been any recent changes in prescribed drugs. Drugs for diabetes mellitus, hypertension, cardiac disorders, hormonal disorders, cancer, arthritis, and psychiatric disorders are potential causes of kidney dysfunction. Antibiotics, such as gentamicin (Garamycin, Cidomycin ), may also cause acute kidney injury. Drug-drug interactions and drug–contrast dye interactions also are potential causes of kidney dysfunction. Explore the past and current use of over-the-counter (OTC) drugs or agents, including dietary supplements, vitamins and minerals, herbal agents, laxatives, analgesics, acetaminophen, and NSAIDs. Many of these agents affect kidney function. For example, dietary supplementation with synthetic creatine, used to increase muscle mass, has been associated with compromised kidney function. High-dose or long-term use of NSAIDs or acetaminophen can seriously reduce kidney function. Some agents are associated with hypertension, hematuria, or proteinuria, which may occur before kidney dysfunction. Current Health Problems The effects of kidney failure result in changes in all body systems. Therefore document all of the patient's current health problems. Ask him or her to describe all health concerns, because some kidney disorders cause systemic problems or problems in other body systems. Recent upper respiratory problems, achy muscles or joints, chronic disease, or GI problems may be related to problems of kidney function. Assess the kidney and urologic system specifically by asking about any changes in the appearance (color, odor, clarity) of the urine, pattern of urination, ability to initiate or control voiding, and other unusual symptoms. For example, urine that is reddish, dark brown or black, greenish, or different from the usual yellowish color usually prompts the patient to seek health care assistance. Urine typically has a mild

but distinct odor of ammonia. An increase in the intensity of color, a change in odor quality, or a decrease in urine clarity may suggest infection. Ask about changes in urination patterns, such as incontinence (involuntary bladder emptying), nocturia (urination at night), frequency, or an increase or decrease in the amount of urine. The normal urine output for adults is about 1500 to 2000 mL/day, or within 500 mL of the volume of fluid ingested daily. Ask about how closely the urine output is to the volume of fluid ingested. The patient usually does not know the exact amount of urine produced. A bladder diary may provide useful data. Also ask whether: Initiating urine flow is difficult •A burning sensation or other discomfort occurs with urination •The force of the urine stream is decreased (in men) •Persistent dribbling of urine is present The onset of pain in the flank, in the lower abdomen or pelvic region, or in the perineal area triggers concern and usually prompts the patient to seek assistance. Ask about the onset, intensity, and duration of the pain, its location, and its association with any activity or event. Renal colic pain may be intermittent or continuous and may occur with pallor, diaphoresis, and hypotension. These general symptoms occur because of the location of the nerve tracts near or in the kidneys and ureters. Physical Assessment The physical assessment of the patient with a known or suspected kidney or urologic disorder includes general appearance, a review of body systems, and specific structure and functions of the kidney and urinary system. Assess the patient's general appearance, and check the skin for the presence of any rashes, bruising, or yellowish discoloration. The skin and tissues may show edema, especially in the pedal (foot), pretibial (shin), and sacral tissues and around the eyes, which is associated with kidney disease. Use a stethoscope to listen to the lungs to determine whether fluid is present. Weigh the patient and measure blood pressure as a baseline for later comparisons. Assess the level of consciousness and level of alertness. Record any deficits in memory, concentration, or thought processes. Family members may report subtle changes. Cognitive changes may be the result of the buildup of waste products when kidney disease is present. Assessment of the Kidneys, Ureters, and Bladder Assess the kidneys, ureters, and bladder during an abdominal assessment. Auscultate before percussion and palpation because these activities can enhance bowel sounds and obscure abdominal vascular sounds.

Inspect the abdomen and the flank regions with the patient in both the supine and the sitting positions. Observe the patient for asymmetry (e.g., swelling) or discoloration (e.g., bruising or redness) in the flank region, especially in the area Listen for a bruit by placing a stethoscope over each renal artery on the midclavicular line. A bruit is an audible swishing sound produced when the vo lume of blood or the diameter of the blood vessel changes. It often occurs with blood flow through a narrowed vessel, as in renal artery stenosis. Kidney palpation is usually performed by a physician or advanced practice nurse. It can help locate masses and areas of tenderness in or around the kidney. Lightly palpate the abdomen in all quadrants. Ask about areas of tenderness or pain, and examine nontender areas first. The outline of the bladder may be seen as high as the umbilicus in patients with severe bladder distention. If tumor or aneurysm is suspected, palpation may harm the patient. Because the kidneys are located deep and posterior, palpation is easier in thin patients who have little abdominal musculature. For palpation of the right kidney, the patient is in a supine position while the examiner places one hand under the right flank and the other hand over the abdomen below the lower right part of the rib cage. The lower hand is used to raise the flank, and the upper hand depresses the abdomen as the patient takes a deep breath (Fig. 68-9). The left kidney is deeper and often cannot be palpated. A transplanted kidney is readily palpated in either the lower right or left abdominal quadrant. The normal kidney is smooth, firm, and nontender. A distended bladder sounds dull when percussed. After gently palpating to determine the outline of the distended bladder, begin percussion on the lower abdomen and continue in the direction of the umbilicus until dull sounds are no longer produced. If you suspect bladder distention, use a portable bladder scanner to determine the amount of retained urine. If the patient reports flank pain or tenderness, percuss the nontender flank first.

Diagnostic test:

Urine Tests Urinalysis Urine for C&S (Culture and Sensitivity) Creatinine Clearance- tests how well creatinine is cleared from the blood; calculated measure of GFR - Good indicator of renal function - Normal range 80-139mL/min/m2

• BUN- renal excretion of urea nitrogen, by product of protein metabolism in the liver

• Influenced by other factors: infection, bleeding, dehydration, protein intake, etc.

• Normal 10-20 mg/dl • Elevation suggestive of kidney dysfunction • Creatinine- end product of muscle and protein metabolism • **Excellent indicator of kidney function** • Normal 0.6-1.3 • Does not increase until 50% renal function is lost • No other pathologic condition raises creatinine level except renal disease • Reversible • Kidneys, Ureters, Bladder (KUB): X-Ray study to check size, shape, position of

kidneys; check for abnormalities; no prep usually • Pelvic Ultrasound: Non-invasive; uses sound waves; detects abnormalities;

full bladder. • CT Scan: With or without contrast; detects abnormalities; may require NPO

and bowel prep if contrast used. • IV Prep: Allergies to dye • Intravenous Urography (old term IVP) ( Intravenous pyelogram) x-ray of

urinary tract utilizing contrast agent. • Prep NPO 8 hours prior • Sensation with injection • Allergies: Dye; Iodine; seafood or shellfish

Renal Arteriogram:

Visualization of renal blood vessels Can identify stenosis, HTN, trauma, etc. X-ray in special procedures Prep- bowel cleaning, light evening meal, NPO, IV, sedation, Femoral artery, catheter, inject radiopaque dye Post procedure- BR 4-6 hours, frequent VS, site for bleeding, check

peripheral pulses, reaction to dye, fluids

Cystoscopic Examination:

Visual inspection of the interior of the bladder, can bx, remove stones, X-ray or OR, local or general Cystoscope is inserted into bladder through urethra Prep: mild sedation, fluids, consent Fill bladder, warn pt. of sensation to void, may have spasms Post procedure bedrest, monitor vitals, urine output, urine for bleeding,

fluids, analgesics Urodynamics (Examines the process of voiding):

• Cystometrogram- evaluates bladder capacity, pressure, voiding reflexes, detrusor muscle quality.

• Patient supine, catheter inserted, fluid instilled into bladder and measures pressure, volume at first urge to void

• Done at bedside or in office • Post void residual -pt. empties bladder and catheterize to establish volume

post void • Bladder scan

Interventions:

• Assess pain level. • Administer analgesics, antispasmodics, and antibiotics as ordered. • Assess voiding patterns. • Assess level of fear. • Explain all procedures to patient. • Instruct patient in relaxation techniques. • Assess patient’s understanding of the procedure. • Provide description of tests in language patient can understand. • Assess patient’s understanding of test results. • Reinforce information provided to patient.

3. Explain nursing care and management of patients with Renal disorders. Acute Pyelonephritis:

Acute inflammatory/infectious process of one/both kidneys Affects renal pelvis and parenchyma, kidney becomes edematous.

Affects tubules, scar tissue can replace normal tissue, tubules atrophy, abscesses may form

Most common organism is E coli Risk factors : pregnancy, obstruction, reflux, catheter use, DM, kidney

stones. S/S: chills, fever, leukocytosis, back pain, flank pain, CVA tenderness,

n/v, bacteriuria, pyuria, h/a, general malaise, painful urination Diagnostic tests: CBC, UA, C/S, KUB, IV urography Medical Management:IV antibiotic initially, then po, analgesics,

antipyretics, antiemetic, identify cause Nursing Management:

Maintain pain, encourage fluids, strict I/O, VS q 4 hours, bedrest until afebrile, observe for edema and signs of renal failure, administer and monitor drug therapy

Patient teaching: adequate fluid intake, empty bladder regularly, perineal hygiene, meds exactly as prescribed

Chronic Pyelonephritis:

Occurs as a result of repeated bouts of acute pyelonephritis S/S: fatigue, h/a, poor appetite, polyuria, excessive thirst, weight loss;

progressive scarring of kidney resulting in renal failure if persistent and recurring infection.

Dx: IV urogram; creatinine clearance, serum Bun/Cr levels Complications: ESRD Management: Prophylactic antimicrobials

Urinary Tract Calculi:

Urolithiasis: stones in urinary tract Nephrolithiasis: stones in kidney Stones form when chemicals and other elements of urine become

concentrated and form crystals Affects 500,000 people in US each year Occurs predominantly in 20’s-50’s Affects more men than women About 75% of calculi contain calcium as one component of the stone

complex- may be calcium oxalate or calcium phosphate Struvite (15%) Uric acid (8%) Cystine (3%)

Risk factors:

Dehydration Infection Obstruction Metabolic factors- elevated uric acid (gout),hypercalcemia, defective

oxalate metabolism (genetic or dietary), renal tubular necrosis, polycystic kidney disease

Cystinuria Certain medications

Medical Manifestation:

Renal Colic* severe pain in flank area begins suddenly, N/V, pallor, diaphoresis, flank pain on side of affected kidney, may radiate to groin if stone is in ureter of bladder.

Obstruction: oliguria or anuria- emergency Dx tests: U/A -RBC’s, WBC’s; C&S; serum WBC, calcium, uric acid,

oxalate, phosphate KUB, IV urogram, Renal Ultrasound, CT

Treatment:

Relief of symptoms Removal or destruction of calculi Prevention of future stone formation Nursing Management- pain management, strain all urine, I/O,

encourage ambulation, high fluid intake to keep urine dilute (output at least 2L/day), daily weights, assess fluid status/renal function, antibiotics, post surgical care,

Relief of symptoms:

Acute attacks- pain management, bedrest and hydration Opioid analgesics- Morphine Sulfate-IV NSAID-ketorolac(Toradol) Spasmolytic agents- Ditropan, Pro-Banthine Non pharmacologic therapies: hot baths; moist heat

Nutritional therapy:

• Based on type of stone

• Calcium phosphate stones: fluids, protein, Na • Calcium oxalate stones: limit oxalate intake; high fluids

• Uric acid stones: purine diet, limit protein • Cystine stones: protein, fluids

Extracorporeal Shock Wave Lithotripsy (ESWL)

Non invasive procedure;uses externally generated waves to pulverize or shatter stones/calculi into small fragments which are then excreted in the urine

Used for stones too large to pass spontaneously, multiple stones, or obstruction

Minimally Invasive Surgical Procedures:

• Ureteroscopy: visualizes stone and removes it.

Minimally Invasive Surgical Procedures:

• Stenting- a small tube is placed in the ureter by ureteroscopy. • Stent dilates the ureter and enlarges the passageway for the stone

Percutaneous ureterolithotomy or nephrolithotomy Needle passed into collecting system of kidney, endoscope to visualize,

stones removed with forceps or a basket device , or lithotripsy to crush stones

Open Surgical Procedures:

• Only done in 1-2% of patients • Nephrolithotomy(kidney), pyelolithotomy(renal pelvis),

ureterolithotomy(ureter), cystotomy(bladder) • Larger flank incision; longer recovery

Urinary Diversion:

• Ureterostomy- diverts urine directly to the skin surface through a stoma.

• Conduit- collects urine in a portion of the intestine, which is then opened onto skin as a stoma.

• Sigmoidostomy- diverts urine to the large intestine. No stoma required. Ileal Reservoir- diverts urine into a surgically created pouch that functions as a bladder. Pt. removes urine by regular self-catheterization Nursing care:

Monitor color, odor, consistency of urine Teach use of external pouching systems (skin care, pouch care,

drainage mechanisms) Teaching self-catheterization (clean technique at home; sterile in

hospital) Assist pt. with psychosocial aspect of urinary diversion Monitor carefully for s/s of UTI*

*Remember signs and symptoms different in elderly population*

Acute kidney Injury:

Rapid decrease in renal function Leads to azotemia-an accumulation of metabolic waste in the blood Uremia- azotemia becomes symptomatic Urine output decreases to oliguria(<400ml/day) Develops over hours to days with progressive inc in BUN, creatinine

and K+ Classified into 3 groups based on cause Prerenal, Intrarenal and

Postrenal Cause sometimes unknown Hypotension, hypovolemia, C.O. and CHF, kidney or urinary tract

obstruction, obstruction of renal arteries or veins May be reversed if above conditions are treated before permanent

damage occurs Types of kidney Injury: Prerenal :

Etiology is outside the kidney that impairs renal blood flow, leading to ischemia in the nephrons and leads to a decrease in renal perfusion

Accounts for 60-70% cases of A.R.F. Prerenal can lead to intrarenal Hypovolemia, Heart failure primary causes

Intrarenal:

Etiology is actual damage to renal tissue resulting in malfunction of glomeruli or renal tubules

Preceded by ATN (acute tubular necrosis) Prolonged ischemia, nephrotoxins, renal artery or vein stenosis, acute

glomerulonephritis

Postrenal:

Caused by actual obstruction of urinary flow Accounts for 1-10% of cases Elderly BPH, renal calculi, trauma, cancers

Phases: Onset Phase: Begins with the precipitating event and continues until oliguria develops. May last hours to days. There is a gradual accumulation of nitrogenous wastes, such as increasing serum creatinine and BUN. Oliguric Phase : urine output less than 400 mL/day (100-400mL/24Hrs) that does not respond to diuretics or fluid challenge

With hypoperfusion, compensatory mechanisms cause urine volumes to fall, leading to reduced renal blood flow and increasing renal ischemia

Typically lasts 10-14 days but can last for several weeks esp in older clients or with preexisting renal insufficiency

Urinary changes, fluid retention, metabolic acidosis Labs: Increased BUN, Serum Creatinine, hyponatremia, hyperkalemia, bicarb deficiency, (metabolic acidosis) Diuretic Phase :( high-output phase)

Often has prompt onset, urine flow increasing rapidly over a period of several days. Diuresis can result in an output of up to 5-10L/day of dilute urine

Kidneys recover, start to excrete wastes but not able to concentrate urine

Creatinine clearance still may be low with increasing BUN & Creatinine Usually occurs 2-6 weeks after the onset of oliguric phase and continues

until the BUN levels ceases to rise May last 1-3 weeks

Recovery Phase:

Increase in GFR Major improvement in first 1-2 weeks Complete recovery may take up to12 months to improve fully

Clinical Manifestations:

• Appears critically ill and lethargic • Skin, mucous membranes dry

CNS: drowsiness, headache, muscle twitching, seizures Assessment:

• Urine: output varies, hematuria, low or fixed specific gravity; inability

to concentrate urine; prerenal: amounts Na in urine; intrarenal: Na in urine

• Diagnostic tests • Lab values

Prevention:

Adequate hydration Prevent and treat shock promptly Monitor central venous and arterial pressures; hourly output Treat hypotension promptly Continually assess renal function Prevent and treat infections promptly Pay attention to wounds, burns, etc. Meticulous care to patients with catheters

Medical Management:

• Diuretic therapy, volume expanders in hypotensive patients; control HTN; restrict fluids during oliguric phase; hyperkalemia (most dangerous); daily weights; monitor edema; I/O; diet modifications

(moderate protein restriction, carb, K restricted); allow pt. to verbalize concerns; avoid nephrotoxic drugs.

Pharmacology Therapy:

• Kayexalate to treat hyperkalemia • IV Dextrose 50%, insulin, and calcium replacement if pt. is

hemodynamically unstable to shift potassium back into cells • Medication doses may have to be reduced in ARF(dig, ACE inhibitors,

Mg) • Diuretics to control fluid volume

Nutritional therapy:

Weigh daily

carbohydrates, mod protein restriction, K restricted, phosphorous restricted, Na restriction

Nursing Management:

Monitor serum electrolytes, cardiac function, resp. status, musculoskeletal status, I/O, edema, JVD, daily weights

Hyperkalemia most life-threatening complication of renal failure Allow patient to verbalize feelings, provide emotional support,

erythropoietin for anemia, avoid nephrotoxic drugs, meticulous skin care, cough and deep breathe, frequent rest periods

Benign Prostatic Hyperplasia:

Enlarged prostate Occurs in approximately ½ of men 50 and older; 90% of men 80 years

and older Obstructs outflow of urine by encroaching on vesical orifice Cause unknown Causes incomplete emptying of bladder and urinary retention UTIs as a result of urinary stasis

Clinical Manifestations:

• Difficulty in starting stream (hesitancy) and continuing urination • Interruption of stream

• in caliber and force of urinary stream • Sensation of incomplete bladder emptying • Dribbling, frequency, nocturia • Complications: acute urinary retention; UTI; sepsis; calculi; renal

failure caused by hydronephrosis; pyelonephritis Lab Assessment:

• Digital rectal exam: uniform, elastic, nontender enlargement • U/A, urodynamic studies, BUN/CR, CBC, PSA • Transabdominal and transrectal ultrasound

Management • Surgery, meds

Pharmacology Therapy:

5- α-Reductase inhibitors-shrink prostate gland, improve urine flow; prevent conversion of testosterone to dihydrotestosterone leading to decrease in size of prostate

finasteride (Proscar) dutasteride (Avodart)

Alpha-1 selective blocking agents-relax smooth muscle of bladder neck and prostate, creating less urinary resistance and improved urinary flow

alfuzosin (Uroxatral terazosin (Hytrin) doxazosin (Cardura) tamsulosin (Flomax) Minimal invasive procedures:

• Transurethral Microwave Therapy: outpatient; microwaves delivered directly to prostate through transurethral probe.

• Transurethral Needle Ablation: outpatient; increases temp of prostate → necrosis →tissue removed.

• Laser procedures (HoLEP); Intraprostatic urethral stents. TURP (transurethral resection of the prostate):

Closed procedure Most common Small pieces removed Complication- Bleeding /Hemorrhage (24 hours)

Continuous Bladder Irrigant (CBI):

CBI flow rate adjusted to keep urine light pink or clear VS Notify MD for bleeding