Title: NUR240 Urinary Tract Stressors: UTI Cystitis Urolithiasis Bladder Ca PKD ARF/CRF
1NUR240Urinary Tract Stressors
UTICystitisUrolithiasisBladder CaPKDARF/CRF
2Kidney Physiology
- Primary role of kidney is regulation of fluid and
electrolyte balance, additional life preserving
functions include - Excretion of metabolic wastes-micturition
- Water and salt regulation
- Maintenance of acid base balance.http//www.kidn
ey.org/ - Regulation of BP
- Stimulation of RBC production
- Regulation of calcium phosphate metabolism.
3Urinary Tract
- Upper urinary tract
- Kidneys 2 bean shaped organs, composed of
nephrons. A complex vascular system. Each weighs
about 8oz. - Ureters extensions of the renal pelvis and
empty into the bladder. - Lower urinary tract
- Bladder, urethra and prostate gland (males).
4 Renal and Urinary Terms
Azotem ia Uremia Dysuria Frequency
Hesitency Micturation Nocturia Oliguria
Polyuria Uremia Urgency Anuria
Serum creatinine Blood urea nitrogen BUN/Creatinine Ratio Glomerular Filtration Rate
5Assessment of Renal and Urinary Tract Systems
- History of disease or trauma
- Urinary patterns
- Relevant meds
- Allergies
- Fluid status-edema
- Pruritis
- BP
- LOC, level of alertness
- Pain assessment
- Numbness and tingling of extremities
- GI symptoms- anorexia, NV, diarrhea
6Urinary Tract Pain
- Kidney- dull ache in costovertebral angle and
radiates to umbilicus - Ureteral pain in back that radiates to abdomen,
upper thigh, testes and labia - Bladder- low abdominal or over suprapubic area
- Renal Colic- flank pain radiating to lower
abdomen or epigastric area, NV
7Diagnostic Tests
- IVP
- CAT Scans
- Renal angiography
- Ultrasounds
- Cystoscopy- Dx and Tx
- Renal Bx- Open/Closed
- UA, urine electrolytes, osmolality
- CS
- Serum creatinine and BUN
- Hgb and Hct
- Creatinine clearance- 24h collection
- KUB
8Cystoscopy
- Pre procedure bowel prep, NPO if general
anesthesia, IVF for adequate urine flow - Post procedure BR for short period
- Pink tinged urine is comon, retention may occur
- Pain in back, bladder spasms and a feeling of
fullness - Encourage large amts of fluids
9Urinary tract infections-described by location in
the tract
- UTI dysuria, frequency, urgency
- Assessment flank pain, cloudy urine, possible
fever. WBCs in urine. - Treatment with antibiotics Fluoroquinolones(Cipro
), nitrofurantoin(Macrobid), - Sulfonamides (Septra, Bactrim)
- Prevention void before and after sex.
- Wipe front to back, showers better than baths.
- No perfumes to perineal area.
- Avoid sitting in wet bathing suits
- Avoid pantyhose with slacks or tight clothing
10UTI-Lower and Upper
- Risk Factors
- Aging
- Increased incidence with DM
- Increased risk of urinary stasis
- Impaired immune response
- Females short urethra, cystocele, rectocele
- Males BPH
- Obstructions tumor, calculi, strictures
11EBP- UTI Bundles
- Assess daily for need for catheter
- Foley bag below level of bladder
- Closed system
- Secure cath to prevent movement, tugging
- Use of smallest size catheter possible
12Cystitis
- Most common UTI (superficial, bladder mucosa)
- Manifestationsdysuria, frequency, urgency,
nocturia, foul odor urine, hematuria - Older patientsnocturia, incontinence, confusion,
behavioral changes, lethargy, anorexia, fever or
hypothermia
13Dx for cystitis
- UA
- Urine for Gram Stain
- Urine for C S
- Evaluation of urinary tract
14Interventions
- Uncomplicated
- Single dose regimen
- Antispasmodics
- Recurrent or chronic
- Sulfonamides
- Antiseptics
- Analgesics
- Surgical Management
15Management of Cystitis
- Increase fluid intake
- Acidify urine
- Ascorbic acid
- Avoid bladder irritants
- Antibiotics based on CS
- Patient teaching
16Upper Urinary Tract Infections
- Pyelonephritis inflammation of kidney caused by
bacterial infection following a bladder infection - Infection begins in lower urinary tract with
organisms ascending into renal pelvis - E coli causes most cases of pyelonephritis
- Affects filtration,reabsorption and secretion
decrease in renal function
17Risk Factors
- Women over age 65
- Older men with prostate problems
- Chronic urinary stone disorder
- Spinal cord injury
- Pregnancy
- Congenital malformations
- Bladder tumors
- Chronic illness HTN, DM, chronic cystitis
- Recurrence is common
18Physical Assessment
- Patient presents with acute distress
- Hx of dysuria, frequency, urgency and other signs
of cystitis - Costovertebral tenderness
- Fever, chills, nausea and flank pain
- N V, malaise, fatigue
- Cloudy urine or hematuria
19Diagnostic Assessment
- UA and CS
- WBC with diff
- Blood Cultures
- Serum creatinine and BUN
- CRP-C-reactive protein
- ESR
- KUB, IVP
20Nursing Interventions
- Pain management
- Antibiotic therapy
- Increase fluid intake
- Monitor temperature
- Provide emotional support
- Assist with personal hygiene
- Follow-up urine cultures
21Assess for Complications
- Septic shock
- Renal Failure
- Hypertension
22Urolithiasis
- Etiology- presence of calculi (stones) in the
urinary tract, by an unknown cause - Recurrence is increased 35-50 in pt with
family hx or if first stone occurs lt25 yrs of age - Increased incidence in males
- Majority of stones (75) are composed of Ca
oxalate or Ca phosphate - Hi doses of Vitamin C
- Conditions causing urinary stasis, dehydration,
urinary retention
23Physical Assessment
- Pain, obstruction, tissue trauma with secondary
hemorrhage and infection - Sharp, severe pain (renal colic) with sudden
onset deep in lumbar region around to side - N V
- Urinary frequency or dysuria
- Pallor, diaphoresis
- VS
- Oliguria, anuria, hematuria
24Diagnostic Assessment
- UA- RBCs, WBCs, bacteria, turbidity,odor
- Serum Ca, PO4, Uric Acid levels
- Elevated serum WBC if infection is present
- KUB, IVP, Xrays, Ultrasound
?
25Non-surgical Management
- Pain management- MSO4, NSAIDS
- Antispasmotics-Ditropan, Pro-Banthine
- Antiemetics- Zofran
- Strain all urine- send stones for analysis
- Increase fluid intake to 3000mL/day
- Client education re meds/diet
26Methods of Stone Removal
- Stenting
- ESWL- Extracorporeal Shock Wave Lithotripsy
- Retrograde ureteroscopy/cystoscopy
- Percutaneous or open ureterolithotomy/pyelolithoto
my/nephrolithotomy
27Urinary Drainage Tubes
- Ureteral Stents
- Maintain ureteral flow in pts with ureteral
obstruction - Divert urine
- Promote healing of ureter
- Maintain patency of ureter after sugery
- Temporary or permanent-inserted via nephrostomy
tube, cystoscopy or open sx.
28Nephrostomy Tubes
- Catheter is placed into renal pelvis for urine
drainage (placed in flank area) - Relieve obstruction, route for insertion of
ureteral stent - Drainage for when ureter doesnt drain
- Administer meds, biopsy
- Never clamp a nephrostomy tube-can lead to
pyelonephritis - Never irrigate without specific order
- Monitor urine output
29Nursing Interventions in client education
- Restrictions based on stone analysis
- Ca Phosphate- Limit foods high in animal protein,
limit Na and Ca intake - HCTZ- to increase Ca reabsorption
- Ca Oxalate- Limit oxalate sources spinach, black
tea, cocoa, beets, pecans, limit Na intake - Uric Acid Limit foods high in purines organ
meats, poultry, fish, gravies, red wine and
sardines. Allopurinol (Zyloprim)
30Assess for Complications
- Hydronephrosis
- Infection
- Ureteral obstruction
31Bladder Cancer
- Etiology about 54,000 new cases yearly, more
common in gtage 60 - Industrial exposure
- Long term use of Cyclophosphamide (Cytoxan) and
Aziothioprine (Imuran) - Tobacco use
- Secondary to mets
32Diagnostic Assessment
- Urinalysis-presence of gross or microscopic
hematuria - Cystoscopy-Bladder-wash specimens and bladder
biopsy - CT scans and MRI to assess for mets
33Physical Assessment
- Painless hematuria- major sign
- Assess general health, exposure to cigarette
smoke, harmful environmental agents - Changes is urinary habits
34Nonsurgical Interventions
- Intravesical immunotherapy- instillation into the
bladder - Bacille Calmette-Guerin (BCG)
- Intravesical chemotherapy-mitomycin (Mutamycin),
Doxorubicin (Adriamycin) - Complications bladder irritation, frequency,
dysuria, contact dermatitis - Systemic chemotherapy
35Surgical Interventions
- Radiation used to reduce tumor size preop
- Cystoscopic tumor resection by excision,
fulguration, laser photocoagulation - TURBT- Transuretheral Resection of Bladder Tumor
- Simple or radical cystectomy-urinary diversion
necessary (ileal conduit)
36Methods of Urinary Diversion After Cystectomy
- Urinary Diversion- divert urine away from kidney
and leaves body via another route - 1.Continent urinary diversion- ureters implanted
into portion( pouch) of ileum (reservoir) for
urine, stoma to abdomen - 2.Incontinent diversions ileal conduit
- 3.Uretersigmoidostomy
- 4. Bladder reconstruction, neobladder
37Post-op Care
- Routine post op care including pain management
- Disturbed body image
- Risk for impaired skin integrity
- Assess urinary drainage
- Sexual dysfunction
- Pt and family education re meds, fluids, care of
urinary diversion system - Referral to www.acs.org and local support groups
38PKDPolycystic Kidney Disease
- Congenital disorder-grapelike clusters of cysts
in the nephrons, progressive - Affects 250,00-500,000 people in the US
- MenWomen
- SS abdominal or flank pain, HTN, nocturia,
Increased abdominal girth, constipation, bloody
or cloudy urine, kidney stones - Renal insufficiency and CRF by age 50-60
39Diagnostic Assessment
- UA-proteinuria, hematuria
- Urine CS
- Rising BUN and Creatinine levels
- Decreased creatinine clearance
- Renal sonograms,CT and MRI
40Interventions
- Mainly supportive- prevent renal damage from HTN,
UTI, obstruction - Pain management-caution with NSAIDS and ASA
- Antibiotic tx for UTIs
- Constipation prevention
- HTN control- ACE inhibitors
- Diet management- Low NA, protein
- Emotional support
41Acute and Chronic Renal Failure
42Acute renal failure (ARF)
- Three causes of ARF
- 1. Prerenal
- 2. Intrarenal (intrinsic)
- 3. Postrenal
- 1.Prerenal- conditions that cause decreased
cardiac output shock, CHF, pulmonary embolism,
sepsis, anaphylaxis,hypotension
43ARF
- 2. Intrarenal - caused by damage to renal tissue.
- Causes glomeruonephritis,infection,drugs
pyelonephritis, vasculitis, acute tubular
necrosis (ATN), tumors - 3. Postrenal- obstructions of outflow of urine
calculi, tumors, atony of bladder, urethral
stricture, trauma
444 Phases of ARF
- Onset
- Oliguric
- Diuretic
- Recovery
- 1.Onset
45ARF
- Oliguric phase urinary output decreased.
- Renal insult,gradual accumulation of nitrogenous
wastes (BUN and creatinine), can last hrs to 3
weeks. - Increasing BUN, hyperkalemia, metabolic acidosis,
hypocalcemia, hypermagnesemia, hyperphosphatemia.
- As plasma levels of nitrogenous wastes increase
changes in - Oxygenation, metabolism, immune response,
perception and coordination result.
46ARF
- 3.Diuretic phase high output phase, up to
10L/day. This phases lasts 1 2 weeks. - 4.Recovery phase begins when BUN stabilizes at
normal, client begins to return to normal
activities. - The mortality rate for ARF- greater than 50 and
for those requiring dialysis, between 60 -90 - Prerenal is the most common cause and is usually
reversible with prompt interventions
47ARF
- Lab findings
- Drug therapy prerenal fluid challenges and
diuretics used to promote perfusion. - Oliguric phase dopamine- small dose, continuous
renal perfusion.
Test Normal Range
Serum Creatinine 0.6-1.2mg/dL
Serum BUN 10-20mg/dL
24hr Urine Creatinine Clearance 80-140mL/min
48ARF
- Diet high calorie diet needed for catabolic
state, if client cannot eat enough, then TPN is
considered. - During the oliguric phase of ARF, the following
diagnoses may apply - High risk for fluid volume excess
- High risk for injury
- High risk for altered nutrition.
49ARF- Physical Assessment
- 1.Prerenal hypotension, tachycardia, decreased
cardiac output and CVP, decreased urine output
and lethargy. - 2. Intrarenal and postrenal-
- Renal oliguria or anuria
- Cardiac- hypertension, tachycardia, JVD,
increased CVP, peripheral edema, efffusions,
50ARF- Assessment
- Respiratory SOB, orthopnea, crackles, pulmonary
edema. - GI anorexia, nausea, vomiting, flank
pain,metallic taste, gastritis - Neuro- lethargy, headache, tremors, confusion,
insomnia, seizures - Hematology-anemia, bruising
- Weight gain. 1kgapprox 1L fluid retained
51Management and Prognosis of ARF
- Tx precipitating cause
- Fluid restriction (500-600mL) plus fluid loss
- Nutritional management
- Measures to lower serum K
- Phosphate binding agents
- TPN or enteral nutrition
- Initiation of dialysis is necessary
52Nursing Management Interventions
- Fluid volume deficit r/t
- Fluid volume excess r/t
- Nutrition Less than body requirements
- r/t
- 4, Impaired gas exchange r/t
- 5. PC Hyperkalemia r/t.
- 6. PC Metabolic acidosis r/t
- 7. PC Decreased Calcium r/t
53- The patient is a 64-year-old man. He visits the
primary care provider because of mild lower
abdominal pain, decreased urine output, and
increased shortness of breath. He is 5 feet, 8
inches tall and weighs 246 pounds. The only drugs
he takes include a daily multivitamin, a beta
blocker, and occasionally acetaminophen for
headache. His past medical history includes
kidney stones 1 year ago and mild hypertension
over the past 5 years. Physical assessment
reveals bilateral crackles in the lung bases.
Vital signs are T, 98.8 F P, 96/min, R, 28/min,
and BP, 148/92. - 1. For which type(s) of acute renal failure is he
at risk? Why? - 2. Do any of his usual drugs increase his risk
for ARF? Which one(s) and why? - 3. Is there any specific assessment data you
could obtain without a prescription to evaluate
his risk for acute renal failure? If so, which
ones and why? -
- The physician prescribes these interventions
- IV placement with a 20-gauge cannula, NS at 20
mL/hr - Accurate intake and output
- Ibuprofen 600 mg orally
- Furosemide 40 mg IV
54Chronic renal failure (CRF)
- CRF is a chronic,progressive, irreversible
disease, leading to end stage renal disease - Five stages
- Stage 1- diminished renal reserve, increased BP,
increased pressure on glomerular apparatus,
decreased ability to concentrate urine- nocturia
and polyuria. - Stage 2 Renal Insufficiency- metabolic wastes
begin to accumulate
55CRF
- Stage 3- End stage renal disease, excessive
amounts urea and creatinine in blood. - Treatment by dialysis is necessary.
- Sodium
- Early in CRF hyponatremia, polyuria causes
sodium depletion. - Later, ESRD sodium retention but dilutional
hyponatremia (masked by fluid volume excess).
56CRF
- Potassium hyperkalemia 7 -8 meq/L, ECG
changes and fatal dysrhythmias. - Acid base balance Acid excretion (H ions)-
restricted results in metabolic acidosis.
Kussmaul respirations. - Calcium and phosphate demineralization.
- Uremic pruritis- toxic accumulation of
nitrogenous wastes.
57CRF- Affects all body systems
- Cardiac Alterations
- Hypertension
- CHF and LV hypertrophy
- Uremic Pericarditis
- Hematologic Alterations
- GI alterations
- MS
- Neuro
- Dermatological
- Endocrine
58Goals of Therapy
- Retain kidney function and maintain homeostasis
as long as possible - Improve nutrition
- Monitor electrolytes
- Manage anemia
- Control HTN
- Maintain glycemic control
- Emotional support
59ESKD Concept Map
60CRF
- Common Nursing diagnoses
- 1. Altered nutrition less than body requirements
r/t nausea, vomiting, decreased appetite, effects
of catabolic state, decreased LOC, altered taste,
or dietary restrictions.
61CRF- Interventions
- Dietary restrictions limit protein intake
- Limitation of fluid intake
- Restriction of K, NA, phosphorous
- Administration of Vitamins and minerals
- Adequate calories to meet metabolic demands
- Collaborate with MD and dietician
62CRF
- Fluid volume excess r/t inability of kidney to
maintain body fluid balance. - Interventions Fluid restriction depends on-
- Urinary output
- Based on fluid wt. gain
- With hemodialysis, 500 -700 ml/day plus amount of
urinary output.
63Nursing Diagnoses
- Impaired skin integrity
- Risk for injury
- Activity intolerance
- Constipation
- Diarrhea
- Anticipatory Grieving
64CRF- Drug Therapy
- Cardiac glycosides digoxin
- Monitor for signs and symptoms of toxicity and
hypokalemia - Vitamins and minerals- FeSo4 and Folic Acid
- Erythropoietin- Epogen, Procrit
- Phosphate Binders- Renagel, Tums
- Stool Softeners- Colace
65Assessment for patients with CRF
- Assess CV and respiratory systems
- VS, especially BP, heart sounds
- Chest pain?, Edema?, JVD?
- Dyspnea?, Crackles?
- Assess nutritional status- Protein, fluid, K, Na,
P restrictions - Weight gain or loss
- Anorexia, nausea, vomiting
66Assessment
- Assess renal status-
- Amount, frequency and appearance urine
- Bone Pain?
- Hyperglycemia-stress need for control
- Assess hematologic status, including_
- Petichiae, purpura, ecchymosis?
- Fatigue?, SOB?
67Assessment
- Assess GI status-
- Stomatitis
- Melena
- Assess neurological status-
- Change in mental status?
- Seizure activity?
- Sensory changes?, Lower ext. weakness?
68Assessment
- Assess Integumentary system-
- Skin integrity
- Discoloration?
- Pruritis?
- Assess lab data, including
- BUN, creatinine, creatinine clearance, CBC,
electrolytes.
69Assessment
- Assess psychosocial status, including-
- Anxiety?
- Maladaptive behavior
- Refer to a community resource group
70Interventions to Manage ESRDPeritoneal Dialysis
and Hemodialysis
- Functions
- Rid the body of excess fluids and electrolytes
- Achieve acid-base balance
- Eliminate waste products, toxins
- Restore internal fluid balance through osmosis,
diffusion and ultrafiltration
71Concepts of Dialysis
- Dialysate solution of electrolytes,modified
salt, acetate, glucose and heparin - Dialyzer- Artificial kidney with a semipermeable
membrane (Hemodialysis) or the peritoneum as a
semipermeable membrane (Peritoneal Dialysis) - Diffusion-
- Osmosis-
72Peritoneal Dialysis
- May be hemodynamically unstable, cant tolerate
anticoagulation. - Peritonitis is a major complication.
- Procedure- surgically inserted tube into
abdominal cavity- infusion of dialysate. - ONE EXCHANGE
- Fill time Infuse 1-2 liters by gravity over 20
min. - Dwell time Dialysate dwells in abdomen over
specified period of time. - Drain Time- 10-15 min. Output usually 100-200mL.
input
73PD
- Fluid then drains out by gravity.
- This effluent contains dialysate, excess water,
electrolytes and nitrogenous wastes. - The number and frequency of exchanges depend on
clients condition and lab data. - Types of PD Continuous ambulatory PD (CAPD),
multiple bag CAPD, automated or continuous cycle.
74PD- Complications
- Peritonitis, manifested by
- Cloudy outflow (effluent)
- Rebound abdominal tenderness
- Abdominal pain
- General malaise
- Nausea, vomiting
- Intervention send C and S, Tx. with appropriate
Antibiotic.
75PD- Complications
- Pain pain initially
- Exit site and tunnel infection
- Insufficient flow of dialysate
- Dialysate leakage.Dyspnea
- Formation of fibrin clots
- Altered body image
76Care of the Tenckhoff Catheter
- Mask for yourself and client
- Put on clean gloves. Remove the old dressing,
remove contaminated gloves. - Assess area for signs of infection, swelling,
redness, or discharge around catheter site. - Use aseptic technique
- Sterile field, 2 4x4s, cotton swabs soaked in
providone iodine, put on sterile gloves. - Use cotton swabs to clean around catheter site,
in a circular motion. - Apply pre-cut gauze pads over catheter site.
- Tape edges of gauze pads.
77Care of patient during PD
- Before treatment monitor vitals, weight, lab
values. - During dialysis continually monitor pt., VS
taken regularly, assess for pain, assess catheter
site for leaking.. Monitor dwell time, and
document. - Record amount outflow, note clarity of effluent,
I and O.
78Hemodialysis
- http//kidney.niddk.nih.gov/kudiseases/pub/
- Vascular access AV fistula,anastomosis of an
artery and a vein or AV shunt - Temporary double lumen catheter in subclavian, IJ
or femoral vein - Pre-dialysis Interventions-
- Assess patency bruit, thrill,distal pulses
- Common complications of access-
- Thrombosis or stenosis, infection, aneurysm
formation, ischemia, bleeding - Determime if meds should be held
79Post Dialysis Nursing Care
- Assess for Complications
- Hypotension
- Headache
- Nausea, vomiting
- Malaise
- Dizziness
- Muscle cramps
- Monitor BUN/Creat/Lytes/Hct
- LOC
- Bleeding
80HD
- Heparinization used for dialysis
- All invasive procedure avoided 4-6 hrs. after
dialysis. - Nurse monitors for signs of hemorrhage during
dialysis and 1 hr. after. - Complications Disequilibrium syndrome
- Infectious diseases can be transmitted,
hepatitis and HIV
81HD
- Nursing Care- Get report.
- Weigh client before and after dialysis
- Know the clients dry weight
- Measure vitals, observe for bleeding
- Assess LOC, HA?, nausea? Vomiting?
82Renal Transplantation
- Candidates must be
- Free from medical problems
- Usually age 40 70 years old.
- Candidates excluded
- Active infection
- IV drug abuse
- Malignant neoplasm
- Severe obesity
- Acute vascultitis
- Severe psych problems
- Long standing pulmonary disease
- Advanced cardiac disease
83Renal Transplantation
- Donors- Absence of systemic disease/ infection
- No history of cancer
- Absence hypertension and renal disease
- Adequate renal function diagnostic tests.
84Renal Transplantation
- Complications-
- Rejection- immunosuppressive drug therapy,
corticosteroids. - Renal artery stenosis HTN, bruit, decreased
renal function. - Post op care- Monitor vitals, renal function, I
and O, urine output, color. - Diuretics may be ordered.
85Renal Transplantation
- Daily weights
- Carefully monitor I and O.
- Monitor for electrolyte imbalances.
- Patient teaching for discharge regarding meds,
diet, wound care,signs of infection and
rejection, and follow up care with PMD.
86Review of Terminology
- Acute Renal Failure
- Usually temporary and may be reversed, leaving no
permanent or serious damage to kidneys - Sudden loss of the ability of the kidneys to
excrete wastes, concentrate urine and conserve
electrolytes
- Chronic Renal Failure
- Long term and irreversible
- Usually occurs over a number of years as the
internal structures of the kidney are slowly
damaged