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ANATOMY, PHYSIOLOGY, DIAGNOSTIC TESTS and THERAPY of RENAL and URINARY DISORDERS:
Objectives 1-15

1. Compare and contrast kidney function with functions of the ureters, bladder, and urethra.
What does kidney do?
Maintain body fluid volume and composition
Filter waste products
Acid base balance
Erythropoietin for RBC
Convert Vit D to active form
Note: nephron functional unit of kidney which forms urine from blood
Juxtamedullary nephrons are longer and dip deeply into medulla: concentrate urine during times of low fluid intake to allow
continued excretion of wastes with less fluid loss
Bladder: stores urine

2. Describe the physiologic processes involved in urine formation, including filtration, reabsorption,
and secretion. (glomerular filtration, tubular reabsorption, tubular secretion/ filtration, diffusion, active
Transport and osmosis)
SIMPLE NURSING
Patho Of the Kidneys Part 1

Kidney Function PART 2 (GFR)

Filtration
Afferent arteriole brings blood to glomerulus ( series of specialized capillary loops with cap walls that have pores bw/endothelial and
epithelial cells for filtering) where capillaries filter water, electrolytes, and small particles (creatinine, urea nitrogen, glucose) from blood to
make urine Bowmans capsule (glomerular filtrate) PCT (tubular filtrate) Descending loop of Henle Ascending Loop of Henle
Cortex DCT Collecting ducts papillae renal pelvis

Normal GFR: 125/mL/min 1-3 L excreted each day as urine; rest absorbed back into circulatory system
GFR controlled by BP and blood flow
Kidneys self-regulate so GFR constant - selectively constricting and dilating afferent/efferent arterioles; if systolic BP<65 to 70
then self-regulation processes not effective
NOTE: large particles: blood cells, albumin and other proteins are too large to filter thru glomerular capillary walls therefore not normally
present in final urine!

Juxtaglomerular complex (afferent arteriole, efferent arteriole, DCT) - produce and store renin

Renin: hormone helps regulate blood flow, GFR, and BP

Aldosterone: hormone regulates fluid and electrolyte balance by increasing kidney reabsorption of Na and water and restoring BP, blood
volume, blood Na levels, promotes excretion of K (drawing out of the tubules into the capillaries to be reabsorbed by the body)

Renin secreted when sensing cells in DCT (macula densa) sense changes in blood volume, pressure, or blood Na level is low renin
converts angiotensinogen Lungs ACE/ angiotensin 1 Liver angiotensin 2 Adrenal secretion of hormone aldosterone

Tubular Reabsorption - 2nd process in urine formation

Reabsorption of most filtrate keeps normal urine output at 1-3 L/day; prevents dehydration
Filtrate tubular parts of nephron (most water and electrolytes reabsorbed from tubular lumen of nephron into peritubular capillaries)
returns most 99% filtered water, electrolytes, and other particles to blood
PCT - most water reabsorption occurs here; some in DCT
DCT more permeable with Vasopressin (ADH) and aldosterone
Vasopressin increases tubular permeability to water-water leaves the tube and reabsorbed back into capillaries
Vasopressin increases arteriole constriction alters BP affecting amts of fluid and particles exiting glomerular capillaries
Aldosterone promotes reabsorption of Na in DCT
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3. Discuss the renal regulatory mechanisms related to fluid, electrolytes, acid-base balance, and blood
pressure.
Too Little volume
Juxtaglomerular complex- made of afferent (incoming) arteriole, efferent (exiting) arteriole and DCT (distal convoluted tubule).
These
structures store renin. When DCT baroreceptors called macula densa sense low volume, low blood volume or low sodium, then
renin is
released.
Renin converts to a ngiotensinogen in LUNGS the Angiotensinogen Converting Enzyme (ACE) converts it to
Angiotensin 1
Sends it to the liver it is converted to Angiotensin 2
This is a vasopressor (moves blood toward center of body and main circulation)
Angiotensin 2 acts on afferent arteriole and efferent arteriole coming in/out of glomerulus to maintain filtration
pressure.
Also sends it to adrenal gland on kidney
Adrenal releases aldosterone (increases reabsorption of H2O and Na+ in DCT)
It also promotes the excretion of K+ (sodium potassium pump - 2 Na+ out, 1 K+ out)
When volume is low, erythropoietin is secreted and action on red marrow of long bones to produce more RBC

Carotid artery has stretch receptors, when they sense low volume, the send info to pituitary. Pituitary releases ADH. That acts
on distal
tubule to reabsorb more Na+ and H2O.
Too much volume
NP stretch receptor in atria of heart secretes NP, which shuts down ADH and Aldosterone and returns balance

SEE DIAGRAM ATTACHED SOON FOR PICTURE AND INFO -Corinne

Attached at bottom of document

4. Describe the renal-related functions in regard to renin, erythropoietin, and vitamin D.

See above answers
Vitamin D:

5. Describe renal/urinary changes associated with aging.

Kidney: loses cortical tissue and gets smaller with age
Reduced blood flow to kidney cortical loss
Medulla not affected by aging so juxtamedullary nephron functions preserved
Glomerular tubular linings thicken
Both number of gloreruli and their surface areas decrease with aging reduce ability to filter blood and excrete waste products
Tubule length decreases reduce ability to filter blood and excrete waste products
Tubular changes decrease the ability to concentrate urine urgency and nocturnal polyuria
Regulation of sodium, acids, bicarbonate less efficient
Age related impairment in thirst mechanism
Above changes increase risk for disturbances of fluid and electrolyte balance - dehydration and hypernatremia
Hormonal changes decrease renin secretion, aldosterone levels, and activation of Vit D
Blood flow to kidney declines 10% per decade as blood vessels thicken blood flow to kidney not as adaptive leaving nephrons
more vulnerable to damage in episodes of hypo or hypertension
Glomerular filtration rate (GFR) decreases with age
By 65, GFR is 65 mL/min and increases risk for fluid overload
Decline more rapid with diabetes, hypertension or heart failure
Combination of reduced kidney mass, reduced blood flow, and decreased GFR contributes to reduced drug clearance and
greater risk for drug reactions and kidney damage from drugs and contrast dyes
Urinary: changes in detrusor muscle elasticity decreased bladder capacity and reduced ability to retain urine
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Urinary sphincters lose tone and become weaker with age urge to void may cause immediate bladder emptying
Women: weakened muscles in pelvic floor shorten urethra promote incontinence
Men: enlarged prostate gland makes starting urine stream difficult and may cause urinary retention
Cultural Considerations:
African Americans: more rapid age-related decreases in GFR than whites
Kidney excretion of Na less effective in hypertensive African Americans with high Na intake and kidneys have 20% < blood flow as result of
anatomic changes in small blood vessels and intrarenal responses to renin
A.A. greater risk for kidney failure than white
A.A. hearly health exams should include urinalysis, checking for presence of microalbuminuria, evaluating serum creatinine
Chart 65-1
Nursing Focus on the Older Adult
Changes in the Renal System Related to Aging

PHYSIOLOGIC NURSING INTERVENTIONS RATIONALES

CHANGE

Decreased glomerular Monitor hydration status. The ability of the kidneys to regulate water balance
filtration rate decreases with age.
(GFR)

Ensure adequate fluid intake. The kidneys are less able to conserve water when
necessary.

Administer potentially nephrotoxic agents or Dehydration reduces kidney blood flow and
drugs carefully. increases the nephrotoxic potential of many
agents. Acute or chronic kidney failure may
result.

Nocturia Ensure adequate nighttime lighting and a Falls and injuries are common among older patients
hazard-free environment. seeking bathroom facilities.

Ensure the availability of a bedside toilet, Using these items instead of getting up to the
bedpan, or urinal. bathroom can help prevent falls.

Discourage excessive fluid intake for 2-4hr Excessive fluid intake at night may increase
before the patient goes to bed. nocturia.

Evaluate drugs and timing. Some drugs increase urine output.

Decreased bladder Encourage the patient to use the toilet, bedpan, Emptying the bladder on a regular basis may avoid
capacity or urinal at least every 2hr. overflow urinary incontinence.

Respond as soon as possible to the patient's A quick response may alleviate episodes of urinary
indication of the need to void. stress incontinence.

Weakened urinary Provide thorough perineal care after each The shortened urethra increases the potential for
sphincters and voiding. bladder infections.
shortened urethra
in women
Good perineal hygiene may prevent skin irritations
and urinary tract infection (UTI).
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Tendency to retain Observe the patient for urinary retention (e.g., Urinary stasis may result in a UTI, which may lead
urine bladder distention) or urinary tract infection to bloodstream infections, urosepsis, or septic
(e.g., dysuria, foul odor, confusion). shock.

Provide privacy, assistance, and voiding Nursing interventions can help initiate voiding.
stimulants such as warm water over the
perineum as needed.

Evaluate drugs for possible contribution to Anticholinergic drugs promote urinary retention.
retention.

6. Identify important history information in a renal/urological assessment.

Demographics: History of renal problems:
Gender examples: tumors, infections,
Age stones, surgery, UTI.
Socioeconomics
Exposure to Chemicals: Chronic health problems:
Hydrocarbons diabetes, HTN increase the
Gasoline damage to kidney blood
Heavy metals vessels
Drug use

Do they have excessive caffeine intake?

Can increase risk of renal issues like UTI
Do they have high protein diet?
Leads to temporary Kidney problems
Pt. at risk for calculi (stones) they can form new stones.
Ask about changes in thirst or fluid intake.
Endocrine disorders can cause changes in thirst and urine output.

2 Liters of fluid daily is recommended to prevent dehydration or cystitis.

Caffeine is a diuretic and can increase the risk of several renal issues including UTI
High protein diets can lead to temporary renal issues and can lead to new kidney stones for those at risk of stones

WATCH FOR THESE DRUG CLASSES:

Antibiotics-cipro, vancomycin
Analgesics- acetaminophen, NSAID
Cox-2 inhibitor- Celebrex
Proton Pump Inhibitor-Omeprazole
Antivirals-acyclovir
HTN-captopril
Rheumatoid arthritis-infliximab
Psychiatric- lithium
Anticonvulsants-phenytoin
Chemotherapeutics-interferons, cyclosporine

Ask about characteristics of urine (color, odor, clarity)

Ask about pattern of urination and if there are any unusual manifestations
Could include: incontinence, nocturia, frequency, increase/decrease in amount
Ask if they are able to initiate and/or control voiding
Ask if input and output are generally balanced
Normal adult output is 1500-2000 mL/day or within 500 mL of volume ingested
** A bladder diary could be recommended to increase awareness

7. Describe techniques for physically assessing the renal/GU system.

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The patients general appearance
Presence of rashes, bruising or yellowish discoloration
Edema, especially pedal, pretibial, sacral tissues, around the eyes
Lungs - determine if fluid present
Weight and blood pressure for baseline and later comparisons
Level of consciousness/alertness
A review of body systems
Abdominal assessment includes kidneys, ureters, bladder
Inspect abdomen and flank regions in supine and sitting positions
Listen for bruit with stethoscope over each renal artery on midclavicular line
Specific structure and functions
Kidney palpation performed by physician or advanced practice nurse
Bladder percussion, palpation and, if distended, bladder scanner
Assessment of the Urethra
Examine meatus and surrounding tissues
Unusual discharge i.e. blood, mucus, or pus
Inspect skin and mucous membranes of surrounding tissues
Record presence of lesions, rashes or other abnormalities of penis or scrotum or of labia or vaginal opening
Urethral irritation suspected if discomfort with urination
Teach clean perineum by wiping from front to back NEVER back to front
Teach front-to-back technique keeps organisms in stool from coming close to urethra and decreases risk for infections
Cultural Considerations
Female Circumcision/hygiene practices ( female circumcision= increase risk of UTI)

Inspect for
Color, appearance and odor
Hydration/dehydration, excess bilirubin
Odor - signs of UTI, Diabetes, bladder infection

8. Relate the variations in voiding patterns with their descriptive terms and their significance to urinary
conditions, including Best Practices and patient teaching.
Continence - ability to voluntarily control bladder emptying
Urine filling and storage -Detrusor muscle relaxed (sympathetic nervous system fibers prevent contraction), internal sphincter
muscle tone, external sphincter contraction
Bladder fills stretch sensations transmitted to spinal sacral nerves
Control centers for voiding - cerebral cortex, brainstem, lower spinal cord
Urethral closure for continence must have mucosal surfaces in contact and be adhesive - contact depends on presence and
proper function of nerves and muscles; adhesion depends on adequate secretion of mucus-like substances
Maintenance continence- interaction of nerves controlling muscles of bladder, bladder neck, urethra, pelvic
floor as well as factors that close urethra
Micturition (voiding)-reflex of autonomic control triggers contraction of detrusor muscle (closing ureter at UV) to prevent backflow and
simultaneously relaxes external sphincter and muscles of pelvic floor
Voluntary voiding - learned response controlled by cerebral cortex and brainstem
Contraction of external sphincter inhibits micturition reflex and prevents voiding

9. Relate the description of pain to the specific urinary structure and the pathophysiology.
UTI (Lower tract:urethritis, cystitis, prostatitis) (Upper tract: pyelonephritis), Cystitis, kidney, and ureter
stones.
1353 Col. 1 para. 6: Pain
Flank pain and pain in the lower abdomen or pelvic region, or in the perineal area. Onset, intensity, duration, location, association w/any activity or
event.
Kidney & ureteral pain/irritation= severe and spasmodic=termed renal colic-
Renal colic pain radiates to perianal area, groin, scrotum, or labia; can be intermittent or continuous, w/pallor, diaphoresis, and
hypotension.
Occurring with distention or spasm of the ureter: obstruction or stone passing.
This happens because of the location of the nerve tracts near or in the kidneys and ureters.
Chp 66 p1385- severe pain/renal colic flank pain suggests a stone is in the kidney or upper ureter.
Flank pain extending toward abdomen or to the scrotum and testes or the vulva suggests the stones are in the ureters or bladder.
PAIN IS MOST INTENSE WHEN IN MOVING OR WHEN THE URETER IS OBSTRUCTED. Renal colic is said to begin suddenly and is
often described as unbearable. Nausea, vomiting, pallor, and diaphoresis often accompany the pain. STAGHORN CALCULUS rarely
causes pain because it is not moving.
Urethral spasm- excruciating and may cause shock from stimulation of nearby nerves. Stones fet stuck in the bends, causing ureteral obstruction,
ureter dilates; enlargement of the ureter is hydroureter.
GI manifestations happen in this same way due to the kidney and GI organs close proximity, the nerve pathways are similar. Renointestinal reflexes
often complicate the description of kidney problems.
Body manifestations r/t Uremia : Anorexia, nausea and vomiting muscle cramps, pruritus, fatigue, and lethargy.
build-up of nitrogenous waste products in blood r/t kidney impairment.

kidney
Urinary Calculi
Pain in the region of the kidneys or
bladder may signal the beginning of
an infection or the formation of a
stone.
Report needed w/pain, fever,
chills, or difficulty w/urination.
Malignant tumors-
Urothellium (lining of transitional cells
in kidneys)
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ureter bladder urethra
Malignant tumors-urotelium Inflammation from infection or Urothelium tumors
tumors irritation/trauma
INTERSTITIAL CYSTITIS-chronic
INFLAMMATION of the entire lower
urinary tract ( bladder, urethra, and
adjacent pelvic muscles) and
UNRELATED TO AN INFECTION.-
10xs more in women and difficult to Dx,
PAIN:
Suprapubic or pelvic areas, w/radiating
pain to the groin, vulva, or rectum.
Manifestations are associated
w/bladder filling or voiding, usually
accompanied by frequency, urgency
and nocturia.
Cystitis:
Pain and burning on urination
Suprapuberic pain
Men-midline low back (flank) pain
INFECTIOUS CYSTITIS (can lead to
sepsis or
Foley catheterization=Female entry is
by short urethra and Males -the
varmints climb-up the outside of the
catheter itself and go all the way up to
the bladder.
Catheter breaks in a closed system:
allow bacteria to sneak in and move up
the lumen-and surprise!
W/in 48hrs of cath insert.-bacterial
colonization (remember colonization is
bacteria presence w/o or before
infection) begins along urethra (F.) and
catheter (M.), ascending to the bladder,
affecting about 50% of pts. w/in 1wk of
insertion.
Microbes causing infectious cystitis are
bruises, mycobacteria, parasites, and
yeast (fungus), especially Candida
species (develops w/or during long term
antibiotic therapy) and commonly
caused by pathogens from the bowel or
vagina-Most common bacteria is
Escherichia coli, and less common is
Staphylococcus saprophyticus,
Klebsiella pneumoniae & organisms of
the Proteus and Enterobacter species.
NON-INFECTIOUS CYSTITIS
Causes:
Chemical exposure, drugs
(cyclophosphamide (Cytoxan), radiation
therapy, immunologic responses as
w/systemic lupus erythematosus (SLE),
chemicals, irritation from feminine
hygiene spray, spermicidal jellies, long
term use of caths (w/out inf.).
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DISORDER COMPLICATIONS
Gyn. cancers, cancers, pelvic
inflammatory disorder, endometriosis,
Crohns disease, diverticulitis, lupus, or
Tb.
INTERSTITIAL CYSTITIS
U/K Cause.
Infections through blood and lymph.
Lack of Mucin (produced by cells lining
the bladder to maintain integrity and
make it difficult for bacteria to attach to;
concentrated urine irritation interferes
w/production).

Urothelium tumors (bladder cancer)

Blood in urine that is intermittent and
usually painless. Dysuria, frequency,
urgency with infection or obstruction.

10. Discuss the nursing management, including Best Practices and patient teaching the following
diagnostic procedures & lab work:

GFR:Glomerular filtration rate

How well the kidneys are removing wastes/excess fluid from blood
Normal is around 90 (varies according to age)
Below 60 indicates a problem with the kidneys
Less than 15 likely indicates a need for dialysis or transplant
-------------------------------
Serum Creatinine: Normal 0.5-1.1 (women), 0.6-1.2(men) (Iggy pg 1355))
Waste product from the muscles excreted by kidneys
Best indicator of kidney function

Serum Creatinine of 1.5mg/dl or > is risk for AKI (acute kidney injury) from contrast dye and medications.
Monitor baselines and look for actual and risk for changes esp. If patients exposed to nephrotoxic agents
Call provider promptly if any increase above 1.5mg/dl and urine output of less than 0.5ml/hr for 6 hrs or more.
Because this is a big indicator of AKI!!! If fast response Pt. may recover.

BUN Blood Urea Nitrogen Normal 10-20

Measures effectiveness of kidney in excreting urea nitrogen
Urea nitrogen is a byproduct of liver breakdown of protein.
As kidney function declines, BUN levels go up
Other factors that elevate BUN: rapid cell destruction from infection, cancer treatment, or steroid therapy
Blood is a protein; if blood in the tissues(injured tissue) reabsorbed as if general protein, processed by liver and elevated BUN
level
Protein turnover in exercising muscle or from concentration during dehydration
Decreased: liver and kidney dysfunction - liver failure limits urea production
BUN not always elevated with kidney disease/not best indicator for kidney function;
Elevation Suggests kidney dysfunction
Blood urea nitrogen to serum creatinine ratio-determines non-kidney related factors i.e. cardiac output or RBC destruction elevating BUN
level
BUN/Crea normal 6-25

Serum Electrolytes related to kidney function

Urinalysis
The UA is done after the urethral meatus is cleaned and it is collected in midstream during the first void of the morning (ideally)
Should be examined immediately because a delay can result in changes in the test results
Bladder catheterization or suprapubic aspiration can be done
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Urine Culture and Sensitivity (via foley catheter and other)
Clean catch or catheter-derived specimen analyzed for # and type of organisms present
Manifestations of infection and unexplained bacteria in urine specimen bacteria placed in medium w/different antibiotics
effective in killing or stopping growth sensitive or resistant

Creatinine Clearance
[(volume urine x urine creatinine at end of 24 hr)] / serum creatinine (midway thru 12 hr)
Calculated measure of GFR and kidney function based on 24 hr urine collection
Calculated from serum creatinine, age, wt, urine creatinine, gender and race
Age, gender, ht, wt, diet and activity level influence excreted creatinine
Decreases require reducing drug doses; signifies need to explore cause of kidney deterioration
Normal clearance 107-239 mL/min men and 87-107 mL/min women with 24 hr urine sample
Values decrease 6.5 mL/min per decade of life if older than 40 (age r/t decline in GFR)
Bladder Scanners
Noninvasive method of estimating bladder volume
Screen post-void residual volumes and determine need for intermittent catheterization
No discomfort; no patient prep beyond explanation of wt to expect
Explain why procedure done and sensations might experience during procedure
Use male icon on all men and women with hysterectomy
Ultrasound: Check for abnormalities in size, position, shape
To look for kidney stones
Tumors
Kidney,Ureter, Bladder X-rays (KUB)
X-ray of Kidney, ureter, bladder. Can see abdominal structure.
Used for renal calculi, abnormalities in structure
ARE THEY PREGNANT?
Teching: remove all metal, lay flat, non invasive
Intravenous Urography (IVP)
Slide: NPO before 8-12 hrs, bowel prep, nephrotoxic agent. Renal function adequate? Allergy to contrast medium? Patient IV required;
may feel warm sensation and/or salty taste as dye is injected Metformin BOOK Discontinue 24 hrs prior to procedure page 1361 NUrSING
SAFETY PRIORITY Ensure pt does not take metformin after procedure with dye contrast until adequate kidney function determined!
If you are taking metformin when you have your imaging test procedure
.What might happen:The effects of metformin may increase and cause a serious condition called lactic acidosis, especially if you have kidney
problems. Symptoms of lactic acidosis are: feeling very weak, tired, or uncomfortable, unusual muscle pain, trouble breathing, unusual or
unexpected stomach discomfort, feeling cold, dizziness or lightheadedness, suddenly developing a slow or irregular heartbeat.

X-ray exam of your urinary tract. Views kidneys, bladder and ureters
An X-ray dye (iodine contrast solution) injected into a vein in your arm. The dye flows into your kidneys, ureters and bladder,
outlining each of these structures. X-ray pictures are taken at specific times during the exam, so your doctor can clearly see your
urinary tract and assess how well it's working

May be used to help diagnose conditions that affect the urinary tract, such as:

Kidney stones
Bladder stones
Enlarged prostate
Kidney cysts
Urinary tract tumors
Structural kidney disorders
Information regarding urinary tract obstruction

The injection of X-ray dye can cause side effects such as:

A feeling of warmth or flushing

A metallic taste in the mouth
Nausea
Itching
Hives

Rarely, severe reactions to the dye occur, including:

Extremely low blood pressure

A sudden, full-body allergic reaction that can cause breathing difficulties and other life-threatening symptoms (anaphylactic
shock)
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Cardiac arrest

Before your intravenous pyelogram, a member of your health care team will:

Ask you questions about your medical history

Check your blood pressure, pulse and body temperature
Ask you to change into a hospital gown and remove jewelry, eyeglasses and any metal objects that may obscure the X-ray
images
Place an intravenous (IV) line into a vein in your arm through which the X-ray dye will be injected
Ask you to urinate to ensure your bladder is empty for the exam

During intravenous pyelogram

Lie on your back on an exam table. The X-ray machine usually is either attached to or part of the table. An X-ray image
intensifier the part of the machine that obtains the images is positioned over your abdomen. After you're positioned
comfortably on the table, the exam progresses this way:

X-rays are taken of your urinary tract before any dye is injected.
X-ray dye is injected through your IV line.
X-ray images are taken at timed intervals as the dye flows through your kidneys to the ureters and into your bladder.
Toward the end of the exam, you may be asked to urinate again.
You then return to the exam table, so that the health care team can get X-ray images of your empty bladder.
Post: monitor urine output to ensure clearance of contrast med

CT:Uses contrast dye - In some cases the dye can cause kidney failure
Can help to diagnose or detect; tumors or other lesions, obstructive conditions, such as kidney stones, congenital anomalies,
polycystic kidney disease, buildup of fluid around the kidneys, and the location of abscesses
More likely to have kidney damage after the contrast dye if the patient has kidney disease.
Cystography and Cystourethrography (diagnosis or treatment)
NPO night before; light meal can be eaten, bowel prep w/laxative or enemas
Series of x-rays or continuous radiographic visualization w/fluoroscopy
Dye fills bladder; bladder is emptied
Images: structure and function of bladder and urethra
Tumors, rupture or perforation of bladder and urethra, abnormal backflow , distortion from trauma or other pelvic masses
Explain urinary catheter temporary to instill contrast dye into bladder (enhances visibility of lower urinary tract; not absorbed into
blood) (NOT nephrotoxic)
X-rays taken front, back, and side positions.
Voiding cystourethrogram (VCUG) x -ray while pt voids to determine if backflow into ureter; urethral or bladder injury or
pyelonephritis (kidney infection) to examine for urethral trauma and identify causes of urinary tract obstruction
Monitor for infection from catheter
Encourage fluid intake-dilute urine/reduce burning from catheter irritation
Monitor for changes in urine output
(Retrograde)Cystography and urethrography identify structural problems, i.e. fistulas, diverticula, and tumors

Renal Arteriography (Angiography)

Doctors inject dye, contrast material, into your blood vessels which will show up on the x-ray.

This procedure allows doctors to see your veins. Possible problems include:

blood clots
blockages
abnormal structural issues
spasms in the vessels
tumors
high blood pressure in the vessels
widened blood vessels

If you have kidney disease or kidney failure, your doctor may perform this procedure to help monitor your condition. They may also use this
test to assess the extent of these conditions.

NPO 8 hrs
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Meds: Aspirin, for example, can affect your bloods ability to clot. Your doctor may tell you to temporarily stop taking some or all of your
medications before the procedure.

Allergies to:

any medications
latex
iodine substances
any anesthetics
contrast dye

Make sure you let your doctor know if youre pregnant or breastfeeding.

consent form / remove any jewelry.

In most cases, youll receive a sedative before the procedure.

Your doctor will then insert a narrow tube, called a catheter, into your artery. Theyll inject the dye through this tube.

Before injecting the dye, your doctor has to get the catheter into the right position. They do this by carefully guiding it through your blood
vessels until it reaches your aorta.

When the catheter is in position, the dye is injected. Your doctor will take multiple X-rays as the dye travels through your blood vessels. The
dye makes the vessels appear on the X-ray so that your doctor to see if there are blockages.

In some cases, your doctor may choose to treat a problem during the procedure. For example, if they find a clot or tumor, they may inject
medication on the spot to help treat it.

Once the doctor is finished, the catheter will be removed.

Theres small chance youll have other complications such as:

infections
blood clots
nerve injury
damage to an artery

You shouldn't drive for 24 hours, so you should arrange for someone to pick you up after the procedure. Avoid exercise or heavy lifting for
about a week. Your doctor may give you additional instructions

Renal Biopsy
Most performed percutaneously using ultrasound or CT guidance
Prone position
Preliminary images/area prepped and sterile draped; local anesthetic
Needle depth and placement confirmed by ultrasound or CT
Pt holds breath while needle advanced into renal cortex; spring loaded coring biopsy needle
Informed consent required
NPO 4-6 hrs prior
Coagulation studies i.e. platelet count, aPTT, PT, and bleeding time performed prior to surgery
Hypertension aggressively managed before and after
Uremia increases risk of bleeding; dialysis maybe before procedure
Possible blood transfusion to correct anemia

Follow up care: major risk bleeding from biopsy site; monitor 24 hrs dressing site, vital signs, urine output, hemoglobin level, hematocrit
Internal bleed suspected with flank pain, decreasing BP, decreasing urine output or s/s of hypovolemia or shock
Strict bed rest, supine position w/back roll for 2-6 hrs after biopsy; HOB elevated, oral intake of food and fluids ok
After bedrest, limited bathroom privileges
Monitor for hematuria-most common complication; resolves on own 46-72 hrs
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Monitor for aching at site radiating to flank and around front of abdomen-possible bleeding or hematoma
If bleeding IV fluid, packed RBC or both to prevent shock
No bleeding resume general activities after 24 hrs; no heaving lifting, exercising or performing strenous activities for 1-2 weeks; possible
driving restrictions

Cystoscopy and Cystourethroscopy

Endoscopic procedures; preoperative checklist and signed informed consent statement
Urologist give complete description of and reasons for procedure; nurse reinforces info
Examines for bladder trauma (cystoscopy) or urethral trauma (cystourethroscopy) and identify
Causes of urinary tract obstruction
Cystoscopy
Purpose to identify abnormalities of bladder wall and urethral and ureteral occlusions; to treat small obstructions or lesions via
fulguration, lithotripsy, or removal w/a stone basket (chart 65-4)
Used to remove bladder tumors or plant radium seeds into tumor, dilate urethra and ureters w/wout stent placement, stop areas
of bleeding or resect enlarged prostate gland
Performed under general anesthesia or local anesthesia w/sedation (age, general health and expected duration of procedure
considered in decision for which anesthesia)
LIght evening meal, NPO after midnight, bowel prep w/ laxatives or enemas evening before
After sedated, place in lithotomy position
Follow-up Care: monitor for airway patency and breathing, changes in vital signs and urine output
Observe for complications of bleeding and infection
Pt w/out catheter has urinary frequency resulting from irritation from procedure; may be pink tinged urine Monitor for blood clots
or decreased or absent urine output
Irrigate Foley w/sterile saline
Notify urologist if fever w/wout chills or elevated WBCs
Encourage oral fluids - increases urine output, helps prevent clotting, reduce burning w/urination
Bladder biopsy performed during cystoscopy lie still in lithotomy position

BPH PSA (prostate specific antigen) Normal PSA <4ng/mL Following info from Hesi case study:

The presence of prostate-specific antigen (PSA), which is secreted only by prostate tissue, suggests prostate disease. Levels are
extremely high with advanced prostate cancer. Low levels reflect prostate hyperplasia or early prostate cancer. PSA levels are generally
higher in older men than in younger men, even when cancer is not present. The American Cancer Society recommends PSA blood test
yearly for all men over age 50. Men in high-risk groups (African Americans and those with a first degree relative diagnosed with prostate
cancer at an early age) should be tested earlier.
Anatomically, the prostate surrounds the urethra and bladder neck. Positioned in the pelvic cavity, it rests upon the rectum. The American
Cancer Society recommends annual digital rectal exam for all men over age 50. Palpation of hard, irregular nodes on the prostate
suggests cancer. Men in high-risk groups (African Americans, those with a family history) should be tested earlier. The prostate cancer
screening blood test can be falsely elevated if the blood is drawn immediately after a digital rectal exam is done.

Serum sodium is usually monitored in clients who have a TURP, to detect TURP syndrome. Serum osmolality may also be monitored.
TURP syndrome occurs when irrigation fluid (usually sterile normal saline) is absorbed systemically. Irrigation fluid may be absorbed
rapidly (through the prostate venous plexus) or gradually (from retroperineal spaces). TURP syndrome can occur during TURP surgery or
up to 24 hours after surgery. With TURP syndrome, a severe hypervolemic, hyponatremic state occurs. Neurologic and hypovolemic
changes occur. Signs and symptoms vary greatly and may change. These include nausea and vomiting, confusion, hypotension,
hypertension, bradycardia, and visual disturbances. Treatment is symptomatic.

Postop/discharge:
After transurethral resection of the prostate (TURP), a high fluid intake will ensure adequate urine output, which will flush the bladder, keep
it free of clots, and reduce risk of ascending urinary tract infection. Residual bleeding and clots may occur up to six weeks after surgery.
After transurethral resection of the prostate (TURP), regular walking will promote venous return from the lower extremities. Walking is
preferred over sitting, which puts pressure on the surgical area and can cause bleeding. Strenuous exercise should initially be avoided.
Perineal exercises are often prescribed after transurethral resection of the prostate (TURP) to improve muscle tone and promote
continence. Post-void dribbling is common after TURP. This generally subsides as muscle tone improves with perineal exercises. Mr.
Sumo should be taught to contract his anal sphincter for up to 10 seconds without tensing his abdominal, buttock, or inner thigh muscles. It
is recommended that this exercise be performed often, at least 20-30 times per day. In addition, he should attempt to shut off and resume
his urine flow with each voiding.
Heavy lifting increases venous pressure and could cause bleeding. The HCP will advise Mr. Sumo when heavy lifting can be resumed.

11. Describe the methods for collection of the following types of specimens of urine: first-voided morning specimen, midstream
voided, from a catheter, 24-hour, and residual.
TABLE 65-3
Collection of Urine Specimens
 12

NURSING INTERVENTIONS RATIONALES

Voided Urine

Collect the first specimen voided in the morning. Urine is more concentrated in the early
morning.

Send the specimen to the laboratory as soon as possible. After urine is collected, cellular breakdown
results in more alkaline urine.

Refrigerate the specimen if a delay is unavoidable. Refrigeration delays the alkalinization of

urine. Bacteria are more likely to
multiply in an alkaline environment.

Clean-Catch Specimen

Explain the purpose of the procedure to the patient. Correct technique is needed to obtain a valid
specimen.

Instruct the patient to self-clean before voiding: Surface cleaning is necessary to remove
secretions or bacteria from the urethral
Instruct the female patient to separate the labia and use the sponges and meatus.
solution provided to wipe with three strokes over the urethra. The first two
wiping strokes are over each side of the urethra; the third wiping stroke is
centered over the urethra (from front to back).

Instruct the male patient to retract the foreskin of the penis and to similarly
clean the urethra, using three wiping strokes with the sponge and solution
provided (from the head of the penis downward).

Instruct the patient to initiate voiding after cleaning. The patient then stops and A midstream collection further removes
resumes voiding into the container. Only 1 ounce (30mL) is needed; the secretions and bacteria because urine
remainder of the urine may be discarded into the commode. flushes the distal portion of the internal
urethra.

Ensure that the patient understands the procedure. An improperly collected specimen may result
in inappropriate or incomplete treatment.

Assist the patient as needed. The patient's understanding and the nurse's
assistance ensure proper collection.

Catheterized Specimen

For non-indwelling (straight) catheters: The one-time passage of a urinary catheter

may be necessary to obtain an
uncontaminated specimen for analysis or
to measure the volume of residual urine.

Avoid routine use.

Follow the facility's procedures for catheterization technique. These procedures minimize bacterial entry.
 13

For indwelling catheters: Urine is collected from an indwelling

catheter or tubing when patients have
catheters for incontinence or long-term
urinary drainage.

Apply a clamp to the drainage tubing, distal to the injection port. Clamping allows urine to collect in the
tubing at the location where the specimen
is obtained.

Clean the injection port cap of the catheter drainage tubing with an Surface contamination is prevented by
appropriate antiseptic. Povidone-iodine solution or alcohol is acceptable. following the cleaning procedures.

Attach a sterile 5-mL syringe into the port, and aspirate the quantity of urine A minimum of 5mL is needed for culture
required. and sensitivity (C&S) testing.

Inject the urine sample into a sterile specimen container. A sterile container is used for C&S
specimens.

Remove the clamp to resume drainage.

Properly dispose of the syringe.

24-Hour Urine Collection

Instruct the patient thoroughly. A 24-hr collection of urine is necessary to

quantify or calculate the rate of clearance
of a particular substance.

Provide written materials to assist in instruction. Instructional materials for patients, signs, etc.
remind patients and staff to ensure that
the total collection is completed.
Place signs appropriately.

Inform all personnel or family caregivers of test in progress.

Check laboratory or procedure manual on proper technique for maintaining the Proper technique prevents breakdown of
collection (e.g., on ice, in a refrigerator, or with a preservative). elements to be measured.

On initiation of the collection, ask the patient to void, discard the urine, and note Proper techniques ensure that all urine
the time. If a Foley catheter is in use, empty the tubing and drainage bag at formed within the 24-hr period is
the start time and discard the urine. collected.

Collect all urine of the next 24hr.

Twenty-four hours after initiation, ask the patient to empty the bladder and add
that urine to the container.

Do not remove urine from the collection container for other specimens. Urine in the container is not considered a
fresh specimen and may be mixed with
preservative.
 14
12. State the classification, pharmacokinetics, pharmacodynamics, pharmacotherapeutics, main
common side effects and nursing implications, including patient teaching for the following GU/Renal
medications:

WATCH SIMPLE NURSING VIDEOS

Nor-Epinephrine Levaphed (Vasopressor) part 1

Nor-Epinephrine Levaphed (Vasopressor) Part 2

Dopamine & Epinephrine (Positive Inotropic + Pos.

Chronotropic)

Nor-Epinephrine Levaphed (Vasopressor) part 1

Nor-Epinephrine Levaphed (Vasopressor) Part 2

Dopamine & Epinephrine (Positive Inotropic + Pos.

Chronotropic)

Dopamine & Epinephrine

13. Discuss the altered drug response for the individual with kidney disease.
Page 1351 Combo of reduced kidney mass, reduced kidney flow, decreased GFR all contributes to
reduced drug clearance and greater risk for rxns and kidney damage from drugs and contrast dyes in older
adults

14. Discuss drug nephrotoxicity and the effects on kidney function. List most common drugs that are
nephrotoxic
Simple nursing:
Metformin
Vancomycin
Gentamycin
IV contrast

WATCH FOR THESE DRUG CLASSES: (top ten classes from Corinne)
Antibiotics-cipro, vancomycin
Analgesics- acetaminophen, NSAID
Cox-2 inhibitor- Celebrex
Proton Pump Inhibitor-Omeprazole
Antivirals-acyclovir
HTN-captopril
Rheumatoid arthritis-infliximab
Psychiatric- lithium
Anticonvulsants-phenytoin
Chemotherapeutics-interferons, cyclosporine

DISORDERS OF THE URETERS, BLADDER AND URETHRA: Objectives 16-24

 15

16. Describe the epidemiology, clinical findings, diagnostic studies, treatments, complications and
nursing management, including prevention and reduction of risk factors, for u rinary tract infections
(cystitis).
Uti
Cystitis

17. Describe the pathophysiology, clinical findings, and treatment (including surgical treatments such as
bladder suspension and related surgical procedures) and nursing management for patients with
dysfunctional voiding patterns (such as retention and incontinence).

18. Describe the clinical findings, treatment, and related nursing management for the patient with
ureteral and bladder stones.

Urolithiasis: #1 s/s pain! KIDNEY STONE

Formation of stones caused by 3 conditions
Anything that can stagnate urine:
Damage to lining of tract
Obstruction
Immobility and dehydration (urinary stasis and dehydration)
Metabolic factors: hypercalcemia, hyperuricemia( )
decrease sodium can help decrease your calcium build up
Diagnosis: evaluate for bladder obstruction
UA look for infection, RBC
Imaging maybe CT scan- non contrast CT
IV urography will show obstruction
Manage/Tx: pass stone on own- strain urine to watch for stone and bring to provider for analysis

If unable to pass on own, lithotripsy (shock wave to break up stone)

Avoid NSAIDS if lithotripsy ( can affect platelets and clotting)

Can use toradol for pain (NSAID, if no lithotripsy)

Use antibiotics- stone can cause irritation and increased risk of infection
Thiazide diuretic for hypercalciuria
Allopurinol and vitamin B6 for oxalate containing stones
Uric Acid Stone- allopurinol, sodium bicarb or potassium citrate can break down.
hydroureter= flow of urine blocked by a stone in ureter, causing ureter dilation

19. Describe the epidemiology, clinical findings, treatment, types of urinary diversion and related
nursing management for cancer of the bladder and other urinary tumors.

Smoking is #1 risk factor for bladder cancer

Bladder Cancer: urothelial cancer

Treat with BCG-immune medication also used with TB- strain of live bacteria
Radiation
chemotherapy

Ureterostomy- creates a stoma instead of a regular urethra.

Can be catheterized like a urethra.
It is on abdomen
risk for infection

Ileal reservoir- surgically created pouch can hold urine instead of bladder, inside the body
 16
Can be like a colostomy bag on outside as well
Think risk for infection

20. Describe the incidence, pathophysiology, clinical findings, diagnostic studies, treatment, complications and related nursing
management for prostatic hypertrophy: benign and cancerous.

21. Discuss the pathophysiology, assessment, diagnostic findings, medications, and nursing management of the patient with a
neurogenic bladder.

22. Describe the nursing management of patients with the following c

atheter situations: indwelling, suprapubic, intermittent.

23. Describe the nursing management for care of patients with problems of incontinence to include teaching about Cred voiding,
Kegel exercises, bladder training and trigger voiding.

24. Discuss incontinence issues and the nursing management in the aging population.

DISORDERS OF THE KIDNEYS: Objectives 25-35

25. Explain the relationship between hypertension and renal disease.

26. Explain how diabetic nephropathy can affect glucose metabolism and control in the client with diabetes mellitus. Page 1406
Diabetes #1 leading cause of ESKD
Always considered at risk for ESKD
Avoid nephrotoxic agents (iodinated contrast media aminoglycosides) and dehydration
Poor control of hyperglycemia problems of:
Hypertension
Atherosclerosis
Neuropathy (promotes loss of bladder tone, urinary stasis, UTI) more severe/more likely kidney damage
Diabetic nephropathy - vascular complication of diabetes
First manifestation - microalbuminuria (begin screening after 5 years of diagnosis of DM type 1, annually type 2)
Diabetic kidney disease - progressive structural/functional changes
Initially slight increase in size; GFR increased
Any proteinuria needs aggressive treatment/diagnostic workup
Worsening - frequent hypoglycemic episodes and a reduced need for insulin or antidiabetic agents due to kidney metabolize and
excrete insulin so kidney function decreased insulin available longer and less needed indicates worsening complications
Outcomes:
Achieve glycemic control <6.5%
Normalize BP 130/80 mmHg or 125/75 mmHg if proteinuria > 1.0 g/24 hr, serum crea > 1.5 mg/dL
Use drug that block renin-angiotensin-aldosterone system (aldosterone)
Treat dyslipidemia so LDL < 100mg/dL

27. Describe the etiology, pathophysiology, clinical manifestations, diagnostic studies, treatments, complications, and nursing
management of the following conditions, across the lifespan:
nephrotic syndrome pg.1404
Nephrosis (Nephrotic Syndrome) SIMPLE NURSING
Etiology: many causes
Most common is immune or inflammatory process
Can be genetic (Fabry disease)
Increases glomerular permeability allows larger molecules to pass through

Clinical Manifestations:
Protein in urine, decreased albumin levels, edema (less solutes so fluid 3rd spacing)
Severe proteinuria (>3.5g in 24 hour sample)
Low serum albumin (<3g/Dl)
Renal vein thrombosis
May harm liver function
Can cause EKD
Treatment: treat cause of problem. (steroid for inflammation ect.)
ACE inhibitors can decrease protein loss in urine
Heparin can reduce risk of renal thrombosis
If GFR is normal- intake more protein
If GFR Low-dietary protein decreased (Protein follows GFR -If high increase, if low decrease intake of protein)
 17
Pyelonephritis pg. 1400

Acute pyelonephritis the active bacterial infection

Chronic pyelonephritis repeated upper UTI
Reflux reverse flow of urine from bladder up through ureters into kidney

Etiology: structural deformities, urinary stasis (from bedrest and paralysis)

Obstruction (stones, cancer, scars)
reflux (scarring, structural anomalies,bladder tumor, enlarged prostate)
Reduced bladder tone (diabetic neuropathy, spinal injury, neurodegenerative disease)
Catheter placement (esp. with immune compromise and diabetes)
High doses of NSAID or prolonged use

Most common bacteria is e coli, enterococcus faecalis, ascending infection.

Clinical manifestations:
Chronic pyelonephritis (less dramatic) Acute pyelonephritis
HTN Fever
Inability to conserve sodium chills
Cant concentrate urine tachycardia, tachypnea
Nocturia flank, back, and loin pain
Risk of hyperkalemia tender CVA costovertebral angle
Risk of acidosis N&V
Malaise or fatigue
Burning urgency
Nocturia

Diagnostics: inspect flank, palpate for tenderness, Inspect CVA for symmetry, edema, and redness
Urine dip for positive leukocyte esterase, nitrite, blood, WBC, and bacteria.
Urinalysis with culture and sensitivity. (can determine gram pos or neg bacteria)
Blood culture can look for inflammatory markers (c reactive protein, and erythrocyte sedimentation)
Treatment: pain management (NSAIDS,analgesics)
Antibiotics (broad septum 1st line)
Adequate nutrition and at least 2L fluid/day for light yellow urine

Possible surgical interventions depending on cause:

Pyelolithotomy: stone removal from kidney
Nephrectomy: removal of kidney
Ureteroplasty: ureter repair or revision

Glomerulonephritis pg. 1402

Acute Glomerulonephritis SIMPLE NURSING
ACUTE: Causes table 67-3
Group A strep staphylococcus Pneumococcal syphilis
Visceral abscesses infective endocarditis Hep b infectious mononucleosis
Cytomegalovirus histoplasmosis Measles mumps
Toxoplasmosis varicella Cyamidia coxsackievirus(hand/foot/mouth)
Potentially any viral, fungal, parasitic infection
Etiology:Infection often occurs before manifestation of acute glomerulonephritis (GN)
Onset is 10 days after infection
Usually recover fully and quickly

Clinical Manifestations: Assess for s/s of recent infection

Often presents with edema (assess face, hands, eyelids for edema)
Check for s/s of fluid overload (crackles in lungs, S3 heart sounds, gallop rhythm, neck vein distention)
Changes is voiding (color, clarity, odor) often have smokey, reddish, rusty, brown urine.
Check B/P compare to baseline
Watch for fluid and sodium retention (fatigue, lack of energy, N&V, anorexia)
Diagnostics: Urinalysis looking for RBC, and proteinuria (early morning catch- most acidic and most formed elements)
 18
GFR from 24 hour urine catch- protein excretion rate for acute GN may increase from 500mg /24 hrs (normal) to
3g/24hr
Serum albumin is low (loss in urine and fluid retention causes dilution)
Various specimen obtained to look for infection (look for antistreptolysin-O titers, cryoglobulins, IgG, antibodies)
May obtain kidney biopsy (if doesnt clear up or to rule out other things)
Treatment: manage infection think Antibiotics (penicillin, erythromycin, azithromycin)
To prevent infection wash hands!
Stress personal hygiene
If fluid overload then sodium & water restrictions, diuretics
Fluid allowance- 24hr urine output plus 500ml
If oliguria and have increased potassium and BUN
then restrict potassium and protein intake to prevent hyperkalemia and uremia
Plasmapheresis: removal and filtering of plasma to eliminate antibodies may be used.

Teaching: purpose of drugs, understand diet and fluid restrictions, hand hygiene, daily weights, daily B/P. Notify provider with
sudden
increase in weight or B/P

CHRONIC: Causes table 67-2

Systemic lupus schonlein henoch goodpasture syndrome amyloidosis
Diabetic glomerulopathy HIV associated multiple myeloma cirrosis
Viral Hep B, C sickle cell disease infective endocarditis alports syndrome

Etiology: Develops over 20-30 years or longer. Cause rarely known

Kidney atrophies over time and number of functional nephrons decrease.
L/T reduced glomerular filtration and damage, protein can pass through into urine.
Chronic GM always leads to ESKD (end stage kidney disease)

Manifestations: mild proteinuria and hematuria, HTN, fatigue, occasional edema may be only signs
Changes in kidney result from infection, inflammation, or poor perfusion
Diagnostics: Urine output decrease <2g/24hrs.
Specific gravity is fixed at constant dilution level even with variable fluid intake
May see hematuria.
GFR is low
Serum creatinine is high >6mg/DL can be as high as 30
BUN increased often as high as 100-200 mg/DL
Sodium retention but dilution of plasma from fluid excess may result in false low or normal level.
If oliguria, potassium is not excreted and possible hyperkalemia
Hyperphosphatemia is possible
Acidosis is possible (h+ retention, and loss of bicarb)

Kidney abnormally small on x ray, biopsy important

Treatment: slow pace of disease, maintain hydration (prevent reduced blood flow) drug therapy to control uremia, eventually
dialysis,
transplant or death.

RAPIDLY PROGRESSING GLOMERULONEPHRITIS:

Crescentic glomerulonephritis- crescent shaped cells in bowman's capsule
Develops over weeks or months
Causes loss of kidney function.
Ill quickly: HTN, oliguria, fluid and electrolyte imbalance,

Polycystic Kidney Disease pg. 1394 Larger than usual

Etiology: Inherited disorder L/T fluid filled cysts in nephrons
Dominant form: few cysts until in 30s
Recessive form: nearly all nephrons have cysts form birth
Most die in early childhood
100% of pt. Who inherit PKD will have cysts by 30s
No way to prevent, only manage and prolong kidney function by manage HTN
Recommend genetic counseling
 19

Pathophys: Abnormal cell division causes cysts

Overtime cysts grow in size, kidney looks like grape cluster
Damages glomerular and tubular membranes
Nephron and kidney function becomes less effective
Kidneys increase in size (2-3x size) like a football, can weigh >10lbs
Abdominal organs are displaced L/T pain
Increased risk of infection, rupture, and bleeding, L/T more pain

PKD is exacerbated by HTN, enlarging cysts compress kidney L/T ischemia

Compressed vessels decrease blood flow to kidney
Kidney releases renin to increase blood pressure, HTN harms kidney function.creates CYCLE

Cysts can move to other body systems like liver (reduces liver function)
Higher risk of cerebral aneurysms, may rupture and L/T bleeding/sudden death.
Higher risk of kidney stones

Clinical manifestations: PAIN, distended abdomen, flank pain, nocturia, decreased ability to
concentrate urine.
As kidney function declines may see: edema, HTN, anorexia, N&V, pruritus, fatigue.

Diagnostics: U/A shows proteinuria, hematuria, bacteria if infection.

As function declines- increase in BUN,serum creatinine, decrease in creatinine clearance
Renal ultrasound visualizes cysts
Interventions:
Treat infection with bactrim, septra, cipro
Pain management
no NSAIDS (reduce kidney blood flow)
no aspirin (risk of bleeding)
B/P control with ACE inhibitors, Calcium channel blockers, beta blockers, vasodilators,
Diuretics.
Dry heat for flank pain.

Teaching: (box 67-2, pg 1397)

daily B/P- notify provider with changes
Notify provider for change in temp r/t fever think infection
Daily weight
Limit sodium intake r/t HTN
If s/s of UTI -foul smelling urine, change in color.
HEADACHE that does not go away, visual disturbance think cerebral aneurysm
s/s of constipation- drink lots of water, increase fiber.

renal tumors (Wilms renal cell carcinoma, renal cysts)( P. 1407)

Renal cell carcinoma (adenocarcinoma of the kidney) most common type of kidney cancer

Paraneoplastic syndrome: (systemic effects of cancer) are anemia, erythrocytosis(extra rbcs), hypercalcemia, liver dysfunction,
with elevated
enzymes, hormonal effects, and increased sedimentation rate.
Have either anemia OR erythrocytosis not both at the same time
May have blood loss, but that does not cause anemia
Kidney cell production of erythropoietin
Either tumor cells produce large amts of erythropoietin OR
Tumor cells destroy erythropoietin producing kidney cells = anemia
Tumor cells produce parathyroid hormone-causes hypercalcemia
Increase in renin causes HTN
Increase in hCG decreases libido and secondary sex features

Clinical manifestations: Hematuria

Flank pain/abdominal discomfort
Use gentle palpation for masses
 20
Bruit on auscultation
Watch for skin pallor, darkening of nipples, gynecomastia (hormonal changes)
muscle wasting, poor nutritional status, weight loss (late signs)
Diagnosis:
Urinalysis- look for blood
Hemoglobin and hematocrit levels
Hypercalcemia
Increased erythrocyte sedimentation rate
Increased levels of ACTH (adenocortiotrophic hormone)
Treatment: interventions focus on controlling cancer and prevention of mastitis.
Radiofrequency or cryoablation can slow growth -
Good option if one kidney that needs preserved.
Chemotherapy has limited effectiveness
Sorafenib and oral med can slow growth

Most commonly treated by nephrectomy (kidney removal)

Pre-operative Nurse considerations:
Teach what to expect, lines, drains, pain management plan.

Perioperative: Pt. placed on side, kidney to be removed faced up,

May have to remove 11th and 12th rib for better access
Removes all or part of kidney
May remove adrenal gland.
Radical nephrectomy also removes lymph nodes

Postoperative: Assess for hemorrhage and adrenal insufficiency

Look for bleeding, blood under pt.
Distended abdomen, rigid
Decrease in B/P hypotension, decreased urine output, altered LOC
Indicate hemorrhage or Adrenal insufficiency(Addisons disease- hormone production
problem)

Large amount of sodium and fluid loss via urine followed by hypotension
And decreased output (<400ml/24 hr, or <25 ml/hr) may indicate adrenal insufficiency.

2nd kidney may compensate but it may take days or weeks.

Focus. Preserve function of remaining kidney.
Monitor urine for 24 hrs (is there enough?) low for first hour is acceptable, after it indicated
decreased blood flow to kidney.

Check RBC, hemoglobin, and WBC every 6-12 hours first few days

Monitor I&O, daily weight.

Hurts to breath, may increase risk of atelectasis.

Opioid analgesics to control pain
Treat with antibiotics to prevent infection
If s/s of adrenal insufficiency then glucocorticoids

vascular kidney disorder.

Afferent and efferent arterioles

28. Discuss the etiology, pathophysiology, clinical findings, diagnostic studies, treatments,
complications, and related nursing management of the client with renal calculi and other obstructive
disorders.
Obstructive disorders:Primary problems: urinary retention and potential infection
Hydronephrosis-kidney enlarges/urine collects in renal pelvis and kidney tissue
Hydroureter-enlargement of ureter; obstruction where iliac vessels cross or ureters enter bladder
Causes: tumors, stones, trauma, structural defects, fibrosis
Urethral stricture (low in urinary tract) -bladder distention hydroureter hydronephrosis
Urinary obstruction:
increase tubular filtrate pressure,
increase GFR,
 21
necrosis of kidney
Nitrogen wastes retained (urea, creatinine, uric acid) and electrolytes (Na, K, CL, P) retained/acid base imbalances
Permanent damage within 48 hrs - several weeks
Assess:
Hx of childhood urinary tract problems
Usual patterns of elimination
Recent flank or abd pain
Chills, fever, malaise (UTI)
Inspect each flank for symmetry
Gently palpate abd and bladder ( if urine leakage reflects full bladder and possible obstruction)
Urinalysis - bacteria or WBC/infection; tubular epithelial cells present if prolonged obstruction
Normal blood chemistries unless decreased GFR
Decreased GFR increase blood urea and blood urea nitrogen
Serum electrolyte levels off w/increase blood K,P, Ca metabolic acidosis (decreased bicarb)
Diagnosis: ultrasound, CT
Stone - cystoscopic or retrograde urogram procedures
stricture/hydronephrosis - nephrostomy (internal or external drainage/tubes drain to bag or bladder)
NPO 4-6 hrs
CLotting studies (INR, PT,PTT normal or corrected)
Drugs used to decrease hypertension
Moderate sedation w/procedure
Prone position
Ultrasound or fluoroscopic
Local anesthetic needle/wire/catheter ti left in renal pelvis/exterior end to bag or bladder
IMMEDIATELY decreases pressure, prevents further kidney damage leave tube in place until obstruction resolved
Follow up care:
Assess amt in bag hourly for 24 hrs; expected 30 mL/hr
Type of urine drainage bag clear communication in chart
Decrease drainage, back pain tube clogged or dislodged
Assess for leaking urine or blood; red tinged normal for 12-24 hrs gradually clear, watch for fever and change in urine character
NURSING PRIORITY: nephrostomy
Notify provider:
Decrease drainage or stops
Cloudy or foul smelling
Site leaks blood or urine
Back pain

29. etiology, pathophysiology, clinical manifestations, diagnostic studies, treatments, complications, and nursing management of:
acute prerenal failure 60-70% of cases; before kidney, 20:1 BUN to Crea ratio

SIMPLE NURSING VIDEOS THAT EXPLAIN KIDNEY ACUTE KIDNEY DISEASE

3 Minute Acute Renal Failure

Patho Of the Kidneys Part 1

Kidney Function PART 2 (GFR)

4 Stages of Chronic Renal Failure & ESRF

3 Causes of Acute Renal Failure (OTHER THAN Toxic Drugs)

3 Causes of Acute Renal Failure (OTHER THAN Toxic Drugs)

4 Nursing Interventions for Acute Renal Failure 1 of 2

4 Nursing Interventions for Acute Renal Failure 2 of 2

Acute Kidney Injury Causes & Clinical Manifestations

Reduced perfusion - most common cause of AKI in acute care as seen in hemorrhage, renal losses from diuretics, GI losses from
vomiting, diarrhea
Impaired cardiac output 2ndary to MI, heart failure, dysrhythmias, cardiogenic shock
Vasodilation from sepsis, anaphylaxis, antihypertensive meds
Key features of prerenal-hypotension, tachycardia, decreased CO, decreased urinary output, lethargy
 22

Damage to kidney tissue classed as intra or intrinsic renal failure/ reflects injury to glomeruli,
nephrons, or tubules

acute intrarenal failure actual parenchymal damage

Prolonged renal ischemia from myoglobinuria (rhabdo, trauma, burns), hemoglobinuria (transfusion rxn, hemolytic anemia)
Nephrotoxic agents like aminoglycosides, radiopaque contrast, heavy metals, solvents, NSAIDs, ACEIs, acute glomerulonephritis
Key features of intrarenal -oliguria or anuria, hypertension, tachycardia, SOB, orthopenea, n?V, generalized edema and wt gain, lethargy,
confusion

acute postrenal failure (obstruction of urine flow)

Urinary tract obstruction by calculi, tumors, BPH, blood clots

Key features of postrenal -oliguria or anuria, hypertension, tachycardia, SOB, orthopenea, n?V, generalized edema and wt gain, lethargy,
confusion
Kidney compensation with prerenal or postrenal pathology:
Constricting kidney blood vessels
Activating renin-angiotensin-aldosterone pathway
Releasing antidiuretic hormone (ADH)
Which increases blood volume and improve kidney perfusion BUT also
Reduces urine volume oliguria (<400 mL/day) and
Azotemia (retention and buildup of nitrogenous wastes in blood)
Toxins can also cause blood vessel constriction in kidney reduced kidney blood flow, oliguria, azotemia
Inflammation, infection, and damage intracellular damage of tubular system
Immune mediated complexes damage nephrons
Extensive tubular damage tubular cells slough nephrons lose ability to repair themselves
Timely interventions to remove cause of AKI may prevent ESKD page 141
Severe blood depletion can cause kidney injury even if no known kidney problems
Drink 2-3 L/day of water
Hx: ask about imaging procedures w/dye, acute illnesses (influenza, colds, gastroenteritis, sore throats), urine color dark or smoky, any hx of urinary
obstructive problems, manifestations of fluid overload (crackles, dependent and generalized edema, decreased oxygenation, increased resp rate,
and dyspnea
USUALLY NO ANEMIA unless blood loss from another condition or high BUN levels lyse RBCs
Hospital:
Nurses watch for impending kidney dysfunction in assessments/monitoring lab values
Watch for fluid and electrolyte balance
Accurately measure I/Os, check wt and peripheral edema
Note characteristics of urine, report new sediment, hematuria (smoky or red color), foul odor
Immediately report urine output< 0.5 mL/kg/hr persisting more >2 hrs
Report increase in creatinine occurring over hrs or a few days
Watch BUN, serum K, Na, osmolarity, urine specific gravity and electrolytes, serum monitoring
Be aware of nephrotoxic substances, antibiotics, NSAIDs- administer pretreatment oral or IV bolus of fluid volume; watch drug
peak and trough levels
Critical rescue: recognize volume depletion (low urine output, decreased systolic bp, decreased pulse pressure, orthostatic
hypotension, thirst, rising blood osmolarity) Intervene early w/oral fluids or request increase in IV fluid rate to prevent permanent
kidney damage
acute renal failure
Reversible clinical syndrome with sudden and pronounced loss of kidney function
Occurs over hours to days
Results in kidneys failure to excrete nitrogenous wastes
Diagnostics: Early AKI - urine tests (Na level -inability to concentrate urine, specific gravity; presence of urine sediment, myoglobin, or
hemoglobin
Ultrasonography - kidney size/patency, dilation of renal calyces and ducts, stones, hydronephrosis
CT w/out contrast dye-adequacy of blood flow, identify obstruction or tumors
MRI
X-rays of pelvis or kidneys, ureters, bladder -determine cause of AKI - hydronephrosis, stones
Nuclear medicine study( MAG3) -measure GFR and nature of kidney failure
Renal scan - sufficient blood flow
Cystoscopy or retrograde pyelography-identify obstructions of lower urinary tract
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Kidney biopsy - uncertain cause, persistent manifestations, immunologic disease suspected

Ciprofloxacin (Cipro)
sulfamethoxazole and trimethoprim(Septra,
Bactrim)
levofloxacin (Levaquin)
methenamine hippurate (Hiprex)
24
Class:broad spectrum anti-infective
Action: DNA gyrase inhibitor, kills gram neg and positive
bacteria
pharmacodynamics: peak 1-2 hour, half life 1-4hr, excreted in
urine as active product.
Uses: UTI, E-coli, pyelonephritis, prostatitis, STI, infectious
diarrhea, intraabdominal infections, various infections
Precautions: geriatrics, children, breastfeeding, pregnancy,
CV, hepatic disease, hypokalemia
side effects: headache,restlessness, nausea,
diarrhea,seizures, pancreatitis, bone marrow suppression,
stevens-johnson
Teaching: Take whole dose, D/C @ 1st sign of tendon pain,
Dont take meds with these foods :dairy, sodium bicar,
alkaline antacids. Fluids increase to 3L/day to avoid
crystallization in kidneys, Do not take with NSAIDS, lots of
stress of kidney. Can lead to diarrhea, thrush, yeast
infection.,
INCREASES BUN, Creatinine, proteinuria, glucose,
albuminuria, bilirubin, A
ST, ALT, LDH,
BLACK BOX: tendon pain/rupture, myasthenia gravis
Class: Anti infective
Action: interferes with bacterial biosynthesis (2 mechanisms
of action)
pharmacodynamics:
Uses: for severe UTI and as prophylactic for UTI
side effects: Stevens-Johnson, renal calculi, toxic epidermal
necrolysis
Teaching: Sulfa allergy no take, empty stomach with full glass
of water, 1500 ml fluid intake per day, photosensitivity use
sunscreen,
Class: Anti Infective
Action: Interferes with conversion of bacterial DNA
pharmacodynamics: excreted in urine
Uses: UTI, prostatitis, acute pyelonephritis
side effects: headache, N/V, insomnia, photosensitivity,
Stevens Johnson
Teaching: complete full course, 2 hr before antacids, Fe, Ca,
etc., dry mouth, avoid other meds unless approved, monitor
glucose, use sunscreen
Class:
action:
pharmacodynamics:
uses:
side effects:
teaching:
 25

nitrofurantoin (Macrodantin/Macrobid) Class: Urinary tract anitinfective

Action: Inhibits bacterial acetyl-CoA interference with carb
metabolism
pharmacodynamics: excreted as inactive metabolites in urine,
unchanged in urine
Uses: UTI
side effects: dizziness, headach, N/V, diarrhea
Teaching: take with food or milk, shake well before taking, can
cause drowsiness, can turn urine rusty brown, diabetics check
glucose

phenazopyridine (Pyridium) Class: analgesica

Action: analgesic effect on the mucosa lining of the urinary
tract
pharmacodynamics: unknown
Uses:analgesic for UTI
side effects:orange pee, orange sclera can tinge color of
contact lenses
Teaching: limit of 2 days, orange pee, orange sclera/contact
lenses

Indications:: dysuria

oxybutynin chloride (Ditropan XL) Class:anticholinergic

Action: Anticholinergic smooth muscle relaxant
pharmacodynamics:
Uses:smooth muscle relaxant of bladder, overactive bladder
in females, neurogenic bladder
side effects: dryness, urinary retention, constipation, QT
prolongation (monitor for chest pain), increases intraocular
pressure (think glaucoma).
Teaching: dont give to pt with glaucoma, avoid hot weather,
no alcohol
Indications: overactive bladder

bethanechol chloride (Urecholine) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:

darifenacin (Enablex) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:
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tolterodine (Detrol) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:

finasteride (Proscar) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:

tamsulosin (Flomax) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:

B&O (belladonna and opium) Class:anticholinergic, analgesic

Action: smooth muscle relaxant and narcotic pain relief
pharmacodynamics:
Uses: pain relief,postoperative turp (transurethral resection of
prostate) continuous bladder irrigation patients clots in
bladder cause pain and spasms in bladder
side effects: constipation, drowsiness, dehydration (stay
hydrated to avoid dry mouth, dry eyes, etc),
Teaching:

epoetin alfa (Epogen) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:
 27

calcitriol (Rocaltrol Vitamin D3) Class:parathyroid agent, Vit D hormone

Action: increases intestinal absorption of calcium, provided
calcium for bones, increases renal tubular reabsorption of
phosphate.
pharmacodynamics:
Uses: decreased kidney fx body cant active vit D, this puts in
usable form
D3 replacement, hypocalcemia
side effects: Hypercalcemia, anorexia, sleepiness, weakness,
arrhythmias,
Teaching: N/V, anorexia, flank pain, dysrhythmias,
hypocalcemia

If chronic kidney disease need supplement cant makel by

body

furosemide (Lasix) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:

metolazone (Zaroxolyn) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:

lisinopril (Zestril, Prinivil) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:
 28

sodium polystyrene sulfonate (Kayexalate)
Class:potassium removing resin, cation exchange resin
Action: cat ion exchange agent of sodium and potassium
pharmacodynamics:
Uses: Hyperkalemia particularly in pts with chronic kidney
disease (can take time for it to work) Can be oral or retention
enima dose
side effects: Can cause digoxin toxicity (N&V blurred vision,
anorexia),
Teaching: Don't take with sorbitol( can cause diarrhea and
increase colonic necrosis)

calcium acetate (PhosLo) Class:

action:
pharmacodynamics:
uses:
side effects:
teaching:

Class:
action:
dopamine (Intropin) pharmacodynamics:
uses:
side effects:
teaching:

ACE inhibitor Class: ACE inhibitor

Action: I stimulates aldosterone which increases your BP by water and
salt lose K If system blocked lowers BP and K goes up
pharmacodynamics: blocks conversion of angiotension II
Uses: HTN, protective of renal fx in low doses in pt. With diabetes
Teaching: cough may go away it's a common side effect, if cough does
not go away can switch pt to ARB, IMPORTANT bc certain salt
substitutes that use K substitutes do not use with ACE inhibitors,
Side effects: COUGH #1 side effect if doesnt go away then use ARB;
dont take K supplements; angioedema can occur immediately or 10
years later (edema of tongue and can close off their airway)

Insulin, Ca and dextrose to treat hyperkalemia in emergent situation for cardiac changes bc exchange in cells
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