Functions of kidneys:

Urine formation, drug excretion, acid base balance, secretion of renin, activation
of vitamin D, production of erythropoiten
Glomerular filtration

Formation of urine:

Tubular reabsorption
Tubular secretion
Destention of the bladder muscle sends sensory impulses to spinal cord which

Describe urination reflex

activate the parasympathetic motor system to contract detrusor muscles & dialate
the internal urethral sphincter allowing it to relax (voluntarly) resulting in urination

What is the point of incontinance in the

urination reflex?
When is the micturitionreflex activated?

The point where the external urethral sphincter relaxes

It is initiated when 300 to 400 mL of urine form in the bladder, stimulating stretch
receptors within the wall.

Nocturia

Urination during the night

Oliguria

decreased urination (less than 400mL/24hrs)

Enuresis

Bedwetting

Polyuria

Excessive urination (more than 2000mL/24 hrs)

Anuria

absence of urination

Nursing assessment of Urinary

Collection of data about the patient's voiding patterns, habits, and difficulties and

Elimination

a history of current or past urinary problems

Physical Assessment Nursing of Urinary Palpation of bladder,skin color & texture, vitals, lung sounds, edema, orthostatic
Elimination

hypotension (<BP/>HR)

What is the normal daily Urine Output

1000 - 2000 mL every 24hrs

Characteristics of Urine; Color

Characteristics of Urine; odor

Characteristics of Urine: Turbidity

A freshly voided specimen is pale yellow, straw-colored, or amber, depending on

its concentration.
Odor Normal urine smell is aromatic. As urine stands, it often develops an
ammonia odor because of bacterial action.
Fresh urine should be clear or translucent; as urine stands and cools, it becomes
cloudy.
The normal pH is about 6.0, with a range of 4.6 to 8. (Urine alkalinity or acidity

Characteristics of Urine: pH

may be promoted through diet to inhibit bacterial growth or urinary stone

development or to facilitate the therapeutic activity of certain medications.) Urine
becomes alkaline on standing when carbon dioxide diffuses into the air.

Characteristics of Urine: Specific gravity This is a measure of the concentration of dissolved solids in the urine. The normal
range is 1.015 to 1.025.

a high specific gravity usually indicates dehydration and a low specific gravity
indicates overhydration.
Measuring serum creatinine is a useful and inexpensive method of evaluating
Renal function tests: Serum Creatintine

renal dysfunction. Creatinine is a non-protein waste product of creatine

phosphate metabolism by skeletal muscle tissue. Creatinine production is
continuous and is proportional to muscle mass
Blood urea nitrogen (BUN) measures the amount of urea nitrogen, a waste
product of protein metabolism, in the blood. Urea is formed by the liver and

Renal function tests: BUN

carried by the blood to the kidneys for excretion.

Adult: 7-20 mg/100 ml

Uric acid is the end product of purine metabolism. Purines are obtained from both
dietary sources and from the breakdown of body proteins. Organ meats such as
Renal function tests: Uric Acid

liver, kidneys, and sweetbreads, sardines, anchovies, lentils, mushrooms,

spinach, and asparagus are all rich sources of purines. The kidneys excrete uric
acid as a waste product.
A creatinine clearance test measures the rate at which the kidneys clear
creatinine from the blood. A creatinine clearance test compares the serum

Renal function tests: Creatinine

creatinine with the amount of creatinine excreted in a volume of urine for a

clearance

specified time. A 24-hour time frame is most common. At the beginning of the
test, the patient empties his bladder and the urine is discarded. Then, all urine
voided during the specific time period is collected
Potential Fluid Volume Deficit

Nursing Diagnoses associated with

Potential fluid volume deficit

Renal Function Tests

Potential alterations in nutritional requirements for specific nutrients - potassium,
sodium, and protein
Cystoscopy is the direct visual examination of the bladder, ureteral orifices, and
Cystoscopy

urethra with a cystoscope. It is used to view, diagnose, and treat disorders of the
lower urinary tract, interior bladder, urethra, male prostatic urethra, and ureteral
orifices

Intravenous Pyelogram (Excretory

Urography)

Intravenous pyelogram is the radiographic examination of the kidney and ureter

after a contrast material is injected intravenously. It is used to diagnose kidney
and ureter disease and impaired renal function.

Retrograde Pyelogram

Retrograde pyelogram is the radiographic and endoscopic examination of the kidneys

and ureters after a contrast material is injected into the renal pelvis through the ureter.
A renal ultrasound is a noninvasive procedure that involves the use of ultrasound to
visualize the renal parenchyma and renal blood vessels. It is used to characterize renal

Renal Ultrasound

masses and infections, visualize large calculi; detect malformed kidneys; provide
guidance during other procedures, such as biopsy; and monitor the status of renal
transplants and kidney development in children with congenital processes
It is an invasive procedure that involves obtaining a small piece of renal tissue for
microscopic examination. Tissue sample may be obtained by needle and syringe

Renal Biopsy

through a skin puncture or small incision, during an open surgical procedure during
which a wedge of tissue is removed, or through a cystoscope during which a brush is
used to obtain a tissue fragment.
Continuous and unpredictable loss of urine, resulting form surgery, trauma, or physical
malformation.

Total incontinence
Nursing Interventions: Keep skin clean & dry, condom cath
Involuntary loss of less than 50mL of urine. r/t increase in intra-abdominal pressure.
Stress incontinence

Occurs during coughing, sneezing, laughing, or other physical activities. Childbirth,

menopause, obesity, or straining from chronic constipation can also result in urine loss
Involuntary loss of urine is associated with overdistention and overflow of the bladder.

Overflow incontinence

The signal to empty the bladder may be underactive or absent, the bladder fills, and
dribbling occurs. It may be due to a secondary effect of some prostatic or neurologic
conditions
is urine loss caused by the inability to reach the toilet because of environmental

Functional incontinence

barriers, physical limitations, loss of memory, or disorientation.

Common cause in elderly; instituionalized

What are the causes of disorders

Infection, obstructions, cancer, heriditary diseases, chronic disease, traumatic

of the urinary tract?

diseases & metabolic diseases

Factors of UTI's

stasis, past history, contamination, female, reflux, instruments, aging

Signs & symptoms of UTI's

Dysuria, urgency, frequency, incontinence, hematuria, cloudy, foul smelling urine and
confusion in the elderly
Impaired urinary elimination; frequency

NANDA diagnoses of UTI's

Pain/Discomfort
Health maintenance, altered

Urethral Strictures

Narrowing of urethral lumen by scar tissue

Renal Calculi

Nephrolithiasis is the formation of crystal aggregates in the urinary tract results in

kidney stones, formed by one of four substances: (1) calcium, (2) uric acid, (3)
magnesium ammonium phosphates (or struvite), or (4) cystine. More common in men,
average onset 30-50yrs often w/ family history/dietary factors.
Signs and symptoms of Renal

Pain to the costrovertebral angele, groin, flank, genitala, renal colic. Hematuria, anuria,

Calculi

restlessness, absent bowel sounds, N/V, diarrhea

Nursing diagnoses for Renal

Calculi

Acute pain, risk for infection, deficient knowledge

Distention (dilation) of the kidney with urine, caused by backward pressure on the

Hydronephrosis

kidney when the flow of urine is obstructed. The elevated pressure from obstruction
may ultimately damage the kidney and can result in loss of its function

Signs and symptoms

Can begin quickly causing renal colic, pain, pressure, and distention of the bladder.

Hydronephrosis

Can also start of as asymptomatic & slowly progress

Nursing interventions for

Hydronephrosis

Monitor I&O,
Most common following infections by strains of group A, beta-hemolytic streptococci. In
this situation, there is an abnormal immune reaction, causing immune complexes to

Glomerulonephritis

become entrapped in the glomerular membrane, inciting an inflammatory response.

The capillary membrane swells and is then permeable to plasma proteins and blood
cells. Usually follows a strep infection by 10 days to 2 weeks (the time needed for
formation of antibodies).
Oliguria is an early symptom, Na and H20 retention causes edema, particularly of the

Signs and symptoms

face and hands, along with hypertension. Proteinuria and hematuria follow from the

Glomerulonephritis

increased capillary permeability. This may give a smoky hue to the urine ("cola"
colored).
Sudden interruption of kidney function resulting from obstruction, reduced circulation,
or disease of the renal tissue
Results in retention of , fluids; UOP < 400mL/d or 30mL/hr

Acute Renal Failure

Build up of toxins on blood: end products of protien metabolism (azotemia). Usually

reversible with medical treatment
May progress to end stage renal disease, uremic syndrome, and death without
treatment
Results form gradual, progressive loss of renal function
Occasionally results from rapid progression of acute renal failure

Chronic Renal Failure

Symptoms occur when 75% of function is lost but considered cohrnic if 90-95% loss of
function
Dialysis is necessary D/T accumulation or uremic toxins, which produce changes in
major organs

PRERENAL
Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns,
cardiovascular disorders, sepsis
Causes of Acute Renal Failure

INTRARENAL
Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney disease
POSTRENAL
Stones, blood clots, BPH, urethral edema from invasive procedures
Onset 1-3 days with ^ BUN and creatinine and possible decreased UOP
OLIGURIC PHASE UOP < 400/d, Longer the phase lasts poorer prognosis

Stages of Acute Renal Failure

DIURETIC PHASE UOP ^ to as much as 1-3L/d but no waste products, can not
concentrate urinr, excess waste eliminated in blood
RECOVERY PHASE things go back to normal or may remain insufficient and
become chronic lasting up to 1 yr
Monitor I/O, including all body fluids

Acute Renal Failure Nursing

interventions

Monitor lab results

Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness,
EKG changes
watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions

Chronic Renal Failure signs and

Edema, SOB; cracles, wheezing. Blood vessle distention of neck, may be

symptoms

polyuric, oliguric, anuric.

Urethral Strictures

Narrowing of urethral lumen by scar tissue

Nephrolithiasis is the formation of crystal aggregates in the urinary tract results in

Renal Calculi

kidney stones, formed by one of four substances: (1) calcium, (2) uric acid, (3)
magnesium ammonium phosphates (or struvite), or (4) cystine. More common in
men, average onset 30-50yrs often w/ family history/dietary factors.

Signs and symptoms of Renal Calculi

Nursing diagnoses for Renal Calculi

Pain to the costrovertebral angele, groin, flank, genitala, renal colic. Hematuria,
anuria, restlessness, absent bowel sounds, N/V, diarrhea
Acute pain, risk for infection, deficient knowledge
Distention (dilation) of the kidney with urine, caused by backward pressure on the

Hydronephrosis

kidney when the flow of urine is obstructed. The elevated pressure from
obstruction may ultimately damage the kidney and can result in loss of its
function

Signs and symptoms Hydronephrosis

Can begin quickly causing renal colic, pain, pressure, and distention of the

bladder.
Can also start of as asymptomatic & slowly progress
Nursing interventions for
Hydronephrosis

Monitor I&O,
Most common following infections by strains of group A, beta-hemolytic
streptococci. In this situation, there is an abnormal immune reaction, causing

Glomerulonephritis

immune complexes to become entrapped in the glomerular membrane, inciting

an inflammatory response. The capillary membrane swells and is then permeable
to plasma proteins and blood cells. Usually follows a strep infection by 10 days to
2 weeks (the time needed for formation of antibodies).
Oliguria is an early symptom, Na and H20 retention causes edema, particularly of

Signs and symptoms Glomerulonephritis

the face and hands, along with hypertension. Proteinuria and hematuria follow
from the increased capillary permeability. This may give a smoky hue to the urine
("cola" colored).
Sudden interruption of kidney function resulting from obstruction, reduced
circulation, or disease of the renal tissue
Results in retention of , fluids; UOP < 400mL/d or 30mL/hr

Acute Renal Failure

Build up of toxins on blood: end products of protien metabolism (azotemia).

Usually reversible with medical treatment
May progress to end stage renal disease, uremic syndrome, and death without
treatment
Results form gradual, progressive loss of renal function
Occasionally results from rapid progression of acute renal failure

Chronic Renal Failure

Symptoms occur when 75% of function is lost but considered cohrnic if 90-95%
loss of function
Dialysis is necessary D/T accumulation or uremic toxins, which produce changes
in major organs
PRERENAL
Hypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns,
cardiovascular disorders, sepsis

Causes of Acute Renal Failure

INTRARENAL
Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney
disease
POSTRENAL
Stones, blood clots, BPH, urethral edema from invasive procedures

Stages of Acute Renal Failure

Onset 1-3 days with ^ BUN and creatinine and possible decreased UOP

OLIGURIC PHASE UOP < 400/d, Longer the phase lasts poorer prognosis
DIURETIC PHASE UOP ^ to as much as 1-3L/d but no waste products, can not
concentrate urinr, excess waste eliminated in blood
RECOVERY PHASE things go back to normal or may remain insufficient and
become chronic lasting up to 1 yr
Monitor I/O, including all body fluids
Acute Renal Failure Nursing
interventions

Monitor lab results

Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle
weakness, EKG changes
watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions

Chronic Renal Failure signs and

Edema, SOB; cracles, wheezing. Blood vessle distention of neck, may be

symptoms

polyuric, oliguric, anuric.

EARLY STAGE: Diminished renal reserve 50% nephron loss
Kidney function is mildly reduced while the excretory and regulatory function are
sufficiently maintained to preserve a normal internal environment. The patient is
usually problem free.

RENAL INSUFFCIENCY:75% impaired renal capacity decreased urinary

Chronic Renal failure pathophysiology

concentrating ability, anemia, BUN/creatinine levels increase. Factors that can

exacerbate the disease at this stage by increasing nephron damage are:
infection, dehydration, drugs

ESRD:90% of the nephrons are damaged Renal function has so deteriorated that
chronic and persistent abnormalities; Uremic Syndrome
Patient requires artificial support to sustain life, i.e. dialysis, transplant
Chronic Renal failure electrolyte

Na+2 - Hypernatriemia >145mEq/L: fever, restless, increased fluid retention, ^BP,

distubances

edema, decreased UOP

- hyponatremia
<135mEq/L lethargy, headache, CONFUSION, seizures

K+ - Hypokalemia
<3.5mEq/L fatigue, weak irregular pulse, poly uria, hyperglycemia, bradiacardia
- Hyperkalemia
>5.5mEq/L muscle weakness, urine changes (oliguria or anuria), respiratory
distress, decreased cardiac contrantibility, EKG changes, reflexes flaccid

Ca+2 - Hypercalcemia
>11mg/dl anorexia, N/V, fatigue, constipation, dehydration, bradycardia

- Hypocalcemia
<8.5mg/dl convulsions, arrythmias, tetny,and spasms
Disturbance in removal of waste products - azotemia: weakness, fatigue,
confusion, N/V, urea crystals (itching skin)
Chronic renal failure symptoms:

Disturbance in maintaining acid/base balance - Kussmauls respirations (deep &

fast) from acidosis, headache, N/V, fatigue, weakness
Disturbance in hematolgic function -anemia, decrease in RBC survival time
Fluid and dietary restrictions

Chronic Renal Failure Theraputic

Interventions:

Maintain E-lytes
Dialysis to jump start renal function
May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.
Ace inhibitors, calcium channel blokers > hypertension
Skin integrity impairment, Potential alterations in nutritional requirements,

Renal Failure Nursing Diagnoses

Potential Fluid Volume Deficit, Potential for injury related to weakness and
confusion

Uremic Syndrome

A cluster of symptoms related to the retention of nitrogenous substances in the

blood. Symptoms include: fatigue, confusion, N/V, diarrhea, gastritis, itchy skin
PROTIEN & PHOSPHORUS restriction SLOWS progression.

Pre-End Stage Renal Disease Diet

Protien - 0.6 to 1.0g/kg of ideal body weight. <5-6oz (men) & <4oz (women)

Guidelines
Phosphorus - 8-12mg/kg ideal weight or Limit milk to 1/2 cup, 1oz cheese or any
other high phosphorus foods to 1 serving per day.