Care of Clients with Responses

to Altered Urinary Elimination

By:

Ms. Louradel M. Ulbata, MAN, RN
The Renal System
Renal and Urinary Systems
The urinary system produces urine, but
physiologically it may be better understood as a
system that maintains appropriate levels of
many substances in blood plasma.

Anatomy of the Urinary System
Consists of two
kidneys, two
ureters (upper
urinary tract), a
urinary bladder,
and a urethra
(lower urinary
tract).

Urinary system parts and their
functions:
two kidneys - a pair of purplish-brown organs
located below the ribs toward the middle of the
back. Their function is to:
remove liquid waste from the blood in the form of
urine.
keep a stable balance of salts and other
substances in the blood.
produce erythropoietin, a hormone that aids the
formation of red blood cells.

Nephron
The kidneys remove urea from the blood through
tiny filtering units called nephrons.
Each nephron consists of a ball formed of small
blood capillaries, called a glomerulus, and a small
tube called a renal tubule.
Urea, together with water and other waste
substances, forms the urine as it passes through
the nephrons and down the renal tubules of the
kidney.
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Urinary system parts and their
functions:
two ureters - narrow tubes that carry urine from the
kidneys to the bladder.

Muscles in the ureter walls continually tighten and
relax forcing urine downward, away from the kidneys.

If urine backs up, or is allowed to stand still, a kidney
infection can develop. About every 10 to 15 seconds,
small amounts of urine are emptied into the bladder
from the ureters.
Urinary system parts and their
functions:

bladder - a triangle-shaped, hollow organ located in the
lower abdomen. It is held in place by ligaments that are
attached to other organs and the pelvic bones.
The bladder's walls relax and expand to store urine,
and contract and flatten to empty urine through the
urethra.
The typical healthy adult bladder can store up to two
cups of urine for two to five hours.
Normal daily output 1200-1500 mL



Urinary system parts and their
functions:
two sphincter muscles - circular muscles
that help keep urine from leaking by closing
tightly like a rubber band around the opening
of the bladder.

nerves in the bladder -alert a person when it
is time to urinate, or empty the bladder.
Urinary system parts and their
functions:
urethra - the tube that allows urine to pass
outside the body.
The brain signals the bladder muscles to tighten,
which squeezes urine out of the bladder.
At the same time, the brain signals the sphincter
muscles to relax to let urine exit the bladder
through the urethra. When all the signals occur in
the correct order, normal urination occurs.
Women approx 1 -2 in (3-5 cm)
Men approx 8 in (20 cm)


Receives 25% of cardiac
output
The renal artery arises
from abdominal aorta
Divides into smaller
arterioles to form
glomerulus (capillary bed)
responsible for filtration of
plasma
Blood is returned to the
IVC

Vasculature of the kidney - The blood supply of
the kidney is central to its function.
Process of Micturation
Process of emptying the bladder
Urine collects in the bladder until the pressure stimulates
the nerve endings in the bladder wall called (strech
receptors).

This occurs when the adult bladder contains about 250-450
ml of urine, while in children, this can occur at a smaller
volumes (50-200) ml.

Those receptors transmit impulses to the spinal cord
causing the internal sphincter of the bladder to relax and
stimulate the urge to urinate.

Factors Affecting voiding
1. Developmental considerations
2. Food and fluid intake
3. Psychological factors
4. Muscle tone
5. Pathologic conditions
6. Medications
Developmental Considerations
Children
Toilet training can start at the age of 2 years.
Nocturnal enuresis or bed wetting, is the involuntary
passing of urine during sleep.
Effects of aging
Nocturia, increased frequency, urine retention and
stasis, voluntary control affected by physical
problems. (bladder muscle tone and contractility
diminish).
FUNCTIONS OF THE URINARY
SYSTEM
Functions of the Kidneys
Urine Formation: Formed in the nephrons through a
complex three-step process: GF, tubular reabsorption, and
tubular secretion
Excretion of waste products: eliminates the
bodys metabolic waste products (urea, creatinine,
phosphates, sulfates)
Regulation of electrolytes: volume of
electrolytes excreted per day is exactly equal to the
volume ingested
Na allows the kidney to regulate the volume of body
fluids, dependent on aldosterone (fosters renal
reabsorption of Na)
K kidneys are responsible for excreting more than 90%
of total daily intake
RETENTION OF K IS THE MOST LIFE-
THREATENING EFFECT OF RENAL FAILURE

Renin-Angiotensin System
http://en.wikipedia.org/wiki/Image:Renin-angiotensin-aldosterone_system.png
Normal pH 7.35 to 7.45

Kidney performs two major functions
Reabsorbs and returns Bi carbonate from the
urine filtrate to the circulation
Excrete acids in the urine
Regulation of acid base balance
Lost bicarb is replaced in the renal tubular
cells through regeneration of new bicarb via
chemical reactions
Bicarbonate
Result of catabolism of proteins
Phosphoric acid
Sulfuric acid
Unlike CO2 phosphoric and sulfuric acid cant
be eliminated by the lungs

Accumulation of these acids makes blood
more acidic ( lowers the pH) and inhibits cell
function
The body acid produciton
More acid needs to be excreted than can be
directly eliminated as free acid

Binds to ammonia and phosphate to be
excreted and then further excreted by the
kidney
Body acid elimination
Kidney function
Control of water balance: Normal ingestion of
water daily is 1-2L and normally all but 400-500mL is
excreted in the urine
Osmolality: degree of dilution or concentration of urine
(#particles dissolved/kg urine (glucose & proteins are
osmotically active agents)
Specific Gravity: measurement of the kidneys ability to
concentrate urine (weight of particles to the weight of
distilled water)
ADH: vasopressin regulates water excretion and urine
concentration in the tubule by varying the amount of water
reabsorbed.

Adult Average Fluid Gains and Losses
Fluid Gains
Oral fluids 1100-1400ml
Solid foods 800-1000ml
Metabolism 300ml


Total Gains
2200-2700ml
Fluid Losses
Kidneys 1200-1500ml
Skin 500-600ml
Lungs 400ml
GI 100-200ml

Total Losses
2200-2700ml


One pound equals approximately 500mL

So a weight change on 1 lb could indicate fluid
gain or loss of 500
Regulation of Water Excretion
Kidney function
Synthesis of vitamin D to active form: final
conversion of vit D into active form to maintain Ca
balance
Secretion of prostaglandins: important in
maintaining renal blood flow. They have a
vasodilatory effect.
Vasa recta- monitors blood pressure as blood enters
the kidney
BP juxtaglomerular cells secrete renin (hormone)
Renin Angiotensinogen Angiotensin I Angiotension II
=powerful vasoconstriction ( PVR)

Adrenal Cortex-secrete aldosterone (stimulated by
pituitary)
In response to poor perfusion and increasing serum
osmolality
Retained Na and water increase circulating volume and
increase BP
Auto regulation of blood pressure
The ability of the kidneys to clear solutes from
the plasma.
24 hour urine is the primary test
Creatinine is most useful, but any substance can
be measured

Renal Clearance
An endogenous waste product of skeletal
muscle that is filtered at the glomerulus almost
unchanged.
Provides good measure of GFR
Adult GFR 125mL/min -200mL/min.
(1.67-2.0mL/sec)
Decrease in creatinine clearance indicated decline in
renal function


Creatinine
KIDNEY FUNCTION
Regulation of red blood cell production:
Erythropoeitin
- is released in response to decreased
oxygen tension in renal blood flow.
- This stimulates the productions of RBCs
(increases amount of hemoglobin available to
carry oxygen)
The bladder stores urine
Sensation of full bladder is transmitted by
CNS when 150-200mL of urine is reached
At night vasopressin release in response to
decrease intake cause in urine production
making it more concentrated.

Urine Storage
In spinal cord injury, reflex contraction of the
bladder is maintained, but the voluntary
control is lost
Contraction is not sufficient to empty the bladder
completely leaving residual.
50-100mL in the older adult is normal residual

Bladder emptying
Assessment of the Renal and
Urinary Tract Systems
NURSING HISTORY
ASSESSMENT
SUBJECTIVE DATA
1. Childhood Strep throat
2. Presence of renal or urologic congenital defect
3. Exposed to nephrotoxic chemicals(carbon
tetrachloride (fire extinguisher and petroleum
refining, insecticides), phenol (plastics)and
ethylene glycol (antifreeze for heating and
cooling)
4. Smoking cigarettes
5. ABX- aminoglycosides, amphotericin B,
Sulfonamides
Health History
5. Diet- high calcium intake , dehydration (n/v)
6. Level of activity;immobility leads to
demineralization of bones infection and
calculi
7. PAIN- dysuria, flank, costovertebral or
suprapubic
8. Changes in patterns (frequency, urgency,
enuresis, incontinence or nocturia)
9. Changes in consistency (hematuria, pyuria,
dilute or concentrated)
Health History
10. Current medications that affect renal
function
11. Chronic health problems that affect kidney
DM
HTN
Allergies
MS

Health History
Urologic symptoms can mimic N/V/D,
appendicitis, PUD, and cholecystitis

Unexplained anemia


Misc.
Warning Signs of Kidney Disease
Burning or difficulty during urination.
Increase in the frequency of urination,
especially at night.
Passage of bloody appearing urine.
Puffiness around the eyes, or swelling of the
hands and feet, especially in children.
Pain in the small of the back just below the ribs
(not aggravated by movement).
High blood pressure.
PHYSIOLOGIC RESPONSES TO
RENAL DYSFUNCTION
ANEMIA
ACIDEMIA
HYPERKALEMIA
HYPERPARATHYROIDISM
HYPERTENSION
GI BLEEDING
UREMIA -> <15 ml/min
ANEMIA
Brought about as result of decreased
erythropoietin production, the shortened life
span of RBCs, nutritional deficiencies and the
patients tendency to bleed, particularly from
GI tract

Erythropoietin : substance produced by the
kidneys, stimulates the bone marrow to
produce RBCs
Renal Failure: erythropoietin productxn ->
anemia -> fatigue, angina and SOB
ACIDOSIS
Metabolic acid-base regulation is controlled primarily by tubular cells
located in the kidney, while respiratory compensation is accomplished in
the lungs.

Failure to secrete hydrogen ions and impaired excretion of ammonium
may initially contribute to metabolic acidosis.

As kidney disease continues to progress, accumulation of phosphate and
other organic acids, such as sulfuric acid, hippuric acid, and lactic acid,
creates an increased metabolic acidosis.

Inability to reabsorb Sodium Bicarbonate

Metabolic acidosis may contribute to other clinical abnormalities, such as
hyperventilation, anorexia, stupor, decreased cardiac response
(congestive heart failure), and muscle weakness.
HYPERKALEMIA
Hyperkalemia (potassium >6.5 mEq/L) may be an acute
or chronic manifestation of renal failure, but regardless of
the etiology, a potassium level of greater than 6.5 mEq/L
is a clinical emergency.

As renal function declines, the nephron is unable to
excrete a normal potassium load

Caused by decreased excretion, metabolic acidosis,
catabolism and excessive intake (diet, medications,
fluids)
SODIUM AND WATER
RETENTION
Kidneys cannot concentrate or dilute urine
normally

Cannot excrete sodium and water -> EDEMA,
CHF, HYPERTENSION
CALCIUM AND PHOSPORUS
IMBALANCE
Serum Calcium & Phosphate levels have
RECIPROCAL relationship

In renal failure: excretion of PHOSPHATE of the
kidneys serum phosphate level serum
calcium level stimulate the PARATHYROID
GLAND to release PTH (Hyperparathyroism)
calcium leaves the bones bone changes (RENAL
OSTEODYSTROPHY/ UREMIC BONE DISEASE)

production of the active metabolite of Vitamin D
(1,25- Dihydroxycalciferol


Cardiovascular Manifestations
1. Hypertension
- Sodium and water retention
- activation of RAAS

2. Heart Failure & Pulmonary Edema
- Fluid overload

3. Pericarditis
- irritation of the pericardial lining by the
uremic toxins
Genitourinary Effects
Loss of nephrons and increased burden on
those remaining nephrons
Oliguria or anuria in later stages
Albuminuria and increased creatinine and
BUN in urine
Nocturia
Effects on Musculoskeletal System
Disordered Vitamin D metabolism causes
poor absorption of dietary calcium
Overproduction of parathyroid hormone
leaches calcium from bone.
Hypocalcemia and osteoporosis weakens
bone
Hyperuricemia seldom causes gout, but can
cause pericarditis in heart muscle
Effects on Cardiovascular System
Fluid retention leads to edema, CHF and pulmonary
edema
Hypertension is aggravated by vessel wall
remodeling from renin/angiotensin effects
Aldosterone increases vascular volume and pressure
by promoting osmotic resorption of water and sodium
Cardiac arrest risk from sudden rise in potassium
Respiratory Effects
Shortness of breath and tachypnea related to
CHF or pulmonary edema
May develop uremic fetor when urea is
converted to ammonia in saliva, causing very
bad breath
Increased respiratory rate and depth due to
acidosis
Sensory Effects
Peripheral neuropathy- usually in upper
extremities, but may include restless leg
syndrome
Weakness and dizziness
Irritability with risk of developing convulsions,
and mental confusion from cerebral edema
May notice a characteristic smell from uremia
Hyperkalemia may cause tingling around the
mouth
Damage to retina from longstanding diabetes
or HTN may cause visual deficits
Gastrointestinal Effects
Peptic Ulcer Disease is common
Gastroenteritis
Anorexia
Nausea/vomiting
Hematologic Effects
Anemia related to bone marrow suppression
Elevated Parathyroid hormone causes bone
marrow fibrosis
May have blood loss and induced folate
deficiency from dialysis and abnormal
homeostasis due to prolonged bleeding time

Effects on Endocrine System
Decreased estrogen due to effects of uremic
toxins
Decreased testosterone
Increased half-life of insulin, causing it to be
active for longer time, and increased risk of
hypoglycemia
Dermatologic Effects
Sallow yellow discoloration
Skin color changes to increased pallor,
gray/bronze, or increased pigment excreted
through skin causing a sickly tan color
Skin thicker and leathery
Increased ecchymosis and hematoma
Pruritos and excoriation from itching or from
calcium deposits
Dry skin and mucus membranes
Uremic frost similar to sand on skin

DERMATOLOGIC SYMPTOMS
Uremic Frost
deposits of urea
crystal in the skin



Metabolic Effects
Unable to excrete medications or waste
products
Medications and chemotherapy may cause
severe toxicity problems
Unable to maintain electrolyte balance
Increased rate of catabolism, especially with
fever, trauma, or infection
Neurological Effects
Sleep disorders
Impaired concentration and memory,
sometimes mental confusion due to cerebral
edema, and sometimes coma
Irritabilities- hiccups, cramps, twitching,
asterixis (hands flapping during uremic coma)
Peripheral neuropathies
Apprehension and irritability
Reproductive Effects of Uremia
Increased risk for hypertension and severe
complications during pregnancy due to extra
fluids and waste products.
High risk of pre-eclampsia .
Chronic high blood pressure and waste
products in mothers bloodstream can
seriously affect growth and cause harm to the
babys health
PHYSIOLOGIC RESPONSES TO
RENAL DYSFUNCTION
Nausea
Vomiting
Fatigue
Anorexia
Weight loss
Muscle cramps
Pruritus
Changes in mental status
OBJECTIVE DATA
Landmarks for Physical Assessment
of the Urinary System

Costovertebral angle
Costovertebral Angle - Area on the Lower Back
Formed by the Vertebral Column and Downward
Curve of the Last Posterior Rib
Anatomical location of the kidneys and ureters
Landmarks for Physical Assessment of
the Urinary System

Figure 20.3A Landmarks for urinary assessment. A. The costovertebral angle.
A
Landmarks for Physical Assessment of
the Urinary System

Symphysis pubis
Figure 20.3B Landmarks for urinary assessment. B. The rectus abdominis muscles and
the symphysis pubis.
B
Landmarks for Physical Assessment of
the Urinary System
Rectus Abdominis Muscles - Longitudinal
Muscles Extending from the Pubis to the Ribs on
Either Side of the Midline
Guides the location kidney palpation
Landmarks for Physical Assessment
of the Urinary System
Symphysis Pubis - Joint Formed by the Union of
Two Pubic Bones at the Midline
Bladder is cradled under this structure
Other Considerations in Physical
Assessment
Age
Gender
Culture
Physical Assessment of the Urinary System
Techniques

Inspection
Auscultation
Palpation
Percussion
INSPECTION
Assessment of hydration status and skin color
Inspection of the abdomen
Figure 20.5 Inspecting the abdomen from the foot of the bed.
Inspection:
Skin- pallor, yellow-gray, excoriations, changes
in turgor, bruises, texture(e.g. rough, dry skin)
Mouth: stomatitis, ammonia breath.
Face & extremities- generalized edema,
peripheral edema, bladder distention, masses,
enlarged kidney.
Abdomen-abdominal contour for midline mass
in lower abdomen (may indicate urinary
retention) or unilateral mass.
Weight: weight gain 2
nd
to edema, weight loss &
muscle wasting in renal failure.

Deep tendon reflex of knee (and walking heel
to toe (same nerve innervation of continence)
General fatigue and level of alertness


INSPECTION
AUSCULTATION
Auscultation of the right and left renal arteries
Auscultation of the lungs
Figure 20.6 Auscultating the renal arteries.
costovertebral angles
Inspection of the costovertebral angles
Inspection of the flanks
Palpation of the costovertebral angles
Figure 20.7 Palpating the costovertebral angle.
costovertebral angles
Percussion of the costovertebral
angles
Figure 20.8 Blunt percussion over the left costovertebral angle.
costovertebral angles

Palpation of the kidneys
Figure 20.9 Palpating the left kidney.
Should be non palpable with no discomfort
Kidney is located at the costovertebral angle
(12 rib)


Palpating the kidney and bladder
Bladder
Palpation of the bladder
Normal : occasionally feel lower pole of
RIGHT kidney; LEFT KIDNEY is higher
than RIGHT so not palpable

Palpate by
placing hands
in duck-bill
position at
persons
RIGHT flank
Press hands
together and
have person
take deep
breath
Figure 20.10 Palpating the bladder.
BLADDER

Percussion of the bladder
Percussion of the bladder after
voiding beginning midline at the
umbilicus and percussing down
ward listening for change in
sound from tympany to dullness.
Renal system (physical assessment)
Palpation- No costovertebral angle
tenderness, nonpalpable kidney & bladder,
no palpable masses.
Percussion: Tenderness in the flank may be
detected by fist percussion. If CVA
tenderness & pain are present, indicate a
kidney infection or polycystic kidney disease.

Auscultation: The abdominal aorta & renal
arteries are auscultated for a bruit, which
indicates impaired blood flow to the kidneys



DIAGNOSTICS
NON- INVASIVE
Urine examination of
Urine color
Clarity and odor
pH and specific gravity
Detect protein, glucose, and ketone bodies
Sediment-RBC (hematuria) WBC (pyuria)
Casts ( cylinduria), crystals and bacteria
1. Urinalysis and urine culture
Urine can be a variety of
colors, most often
shades of yellow, from
very pale or colorless to
very dark or amber.
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Visual Examination
The depth of urine color is also a crude
indicator of urine concentration
Pale yellow or colorless urine indicates a dilute urine
where lots of water is being excreted.
Dark yellow urine indicates concentrated urine and the
excretion of waste products in a smaller quantity of
water, such as is seen with the first morning urine, with
dehydration, and during a fever.

Visual Examination
Urine clarity refers to how clear the urine is.
clear, slightly cloudy, cloudy, or turbid.
"Normal" urine can be clear or cloudy.

Substances that cause cloudiness but that are
not considered unhealthy include mucus, sperm
and cells from the skin, normal urine crystals, and
contaminants such as body lotions and powders.

Other substances that can make urine cloudy,
like red blood cells, white blood cells, or bacteria,
indicate a condition that requires attention.
RBC
May be asymptomatic
Acute infection
Cyctitis, urethritis, prostatitis, renal calculi,
neoplasm
Bleeding disorders
Medications (heparin, coumadin)


Urinalysis
Proteinuria
Occasional up to 150mg/day primarily albumin is
normal

Dipstick can detect 30 to 1000mg/L of protein
Affected by urine concentration , radiocontrast, pH,
hematuria

Benign causes-fever strenuous exercise, and prolonged
standing

Persistent proteinuria can be- glomerular disease,
malignancies, collagen disease, diabetes,
preeclampsia, hypothyroidim, heart failure, exposure to
heavy metals, medications (NSAIDS, ACE inhibitors)


Urinalysis
Measures density of a solution compared to water
(which is 1.000)
Altered by presence of blood, protein, and casts
in the urine, hydration status
Normal range 1.010-1.030

High fluid intake Decreased specific gravity
Kidney disease Fixed specific gravity
DM, Nephritis, FVD Increases specific gravity



Specific gravity
Most accurate measure of the kidney ability to
concentrate urine. Meaures solute in kg of
water.

Normal osmolality of urine is
200-800mOsm/kg
24hr Urine is 300-900 mOsm/kg
Osmolality
URINE STUDIES
2. URINE CULTURE and SENSITIVITY
- diagnoses bacterial infections of the urinary tract.


3. RESIDUAL URINE
- amount of urine left in the bladder after voiding measured via
catheter (permanent or temporary) in bladder.


4. CREATININE CLEARANCE
- determines amount of creatinine (waste product of protein
breakdown) in the urine over 24 hours
- measures overall renal function; measures GFR
URINE COLLECTION METHODS

1. ROUTINE URINALYSIS

Wash perineal area if soiled.
Obtain first voided morning specimen.
Send to lab immediately.

- should be examined within 1 hour of voiding

URINE COLLECTION METHODS
2. CLEAN CATCH (MIDSTREAM) SPECIMEN for
URINE CULTURE
Cleanse perineal area.

FEMALE
Spread labia and cleanse meatus front to back using antiseptic
sponges.
MALE
Retract foreskin (if uncircumcised) and cleanse glans with antiseptic
sponges.

Have client initiate urine stream then stop.
Collect specimen in a sterile container.
Have client complete urination, but not in specimen container.
URINE COLLECTION METHODS
3. 24-hour URINE SPECIMEN
- preferred method for creatinine clearance test.
Have client void and discard specimen; note time.
Collect all subsequent urine specimens for 24 hours.
If specimen is accidentally discarded, the test must be restarted.
Record exact start and finish of collection; include date and
time.

Renal concentration tests, creatine clearance
and BUN levels are evaluated together

Evaluate severity of kidney disease and
kidney function
Results may be WNL unitl GFR is <50% of
normal


4. Renal function test
Creatinine (CR)
Measures effectiveness of renal function
End product of muscle energy metabolism
Remains fairly constant
Normal range 0.6mg/dL

Blood urea nitrogen (BUN)
Serves as index of renal function
Urea is end product of protein metabolism
Levels affected by protein intake, tissue break down
and Fluid volume changes
Normal 7-18 mg/dL
Serum test
Renal Systems (Diagnostic test)
Vanillymandelic acid (VMA)
- to diagnose pheochromocytoma, a tumor of the
adrenal gland.
- The test identifies an assay of urinary
catecholamines in the urine.
- Instruct to avoid foods such as caffeine, cocoa,
cheese, gelatin at least 2 days prior to beginning of
the collection & during collection.
- Save all urine on ice or refrigerate. Instruct to avoid
stress & to maintain adequate food & fluids during the
test.
Renal Systems (Diagnostic test)
Uric acid- A 24-hour collection to diagnose gout &
kidney disease.
Encourage fluids & a regular diet during testing.
Place the specimen on ice or refrigerate.
KUB (Kidney, ureters, bladder) radiograph-An
x-ray film that views the urinary system & adjacent
structures; used to detect urinary calculi.
Bladder ultrasonography-A noninvasive
method of measuring the volume of urine in the
bladder.
Computed tomography (CT) & MRI-
provide cross-sectional views of the kidney
& urinary tract.

OTHER Diagnostics

PROSTATE SPECIFIC
ANTIGEN
S/Sx of prostate CA mimic BPH
Digital Rectal Exam for patients over 40
(yearly)
Blood specimen for Prostate Specific
antigen(PSA)
Manipulation of prostate can PSA

Digital Rectal Exam
To examine the prostate, position
finger palmar surface down and palpate
posteriorly to locate prostate.
Palpate in a circular motion to increase
ability to identify the lobes and groove.

The prostate should be 2-4 cm long
and triangular.
The two lateral lobes are separated by a
deeper central grove.

Consistency should be firm and
rubbery. Softness can occur with
infection and hardness can occur with
tumors and diseases.

Any feces on finger of gloved hand
should be tested for occult blood.
INVASIVE TESTS
INTRAVENOUS PYELOGRAM (IVP)

Fluoroscopic visualization of the urinary tract after injection with a
radiopaque dye.

NURSING CARE (PRE-TEST)
Assess for iodine sensitivity.
Obtain consent
Inform client he will lie on a table throughout procedure.
Administer cathartic or enema the night before.
Keep the client NPO for 8 hours pretest.
Inform client about possible throat irritations, flushing of face, warmth or a
salty taste that may be experienced during the test

NURSING CARE (POST-TEST)
Force fluids.
Assess venipincture site for bleeding
Monitor V/S for U/O
CYSTOSCOPY
Use of a lighted scope (cystoscope) to inspect the bladder.
- Inserted into the bladder via the urethra.
- May be used to remove tumors, stones, or other foreign material or
to implant radium, place catheters in ureters.

NURSING CARE (PRE-TEST)
Explain to client that the procedure will be done under general/local
anesthesia.
Obtain CONSENT
Confirm consent form is signed.
Administer sedatives 1 hour before test, as ordered.
General anesthesia: Keep client on NPO.
Local anesthesia: offer liquid breakfast.
CYSTOCOPY

NURSING CARE (POST-TEST)

Monitor V/S & I/O
-PINK TINGED/TEA COLORED URINE is expected
-BRIGHT RED URINE/PRESENCE OF LARGE CLOTS shld be
reported
Advise client that burning on urination is normal and will
subside.
Encourage DBE to relieve bladder spasms
Administer sitz baths for back & abdominal pain
Administer analgesics as Rx
Force fluids as prescribed


RENAL ANGIOGRAPHY
the injection of a radiopaque dye through a catheter for examination of
the renal artery supply
NURSING CARE ( PRE-TEST)
Obtain consent
Assess client for allergies to iodine, seafoods & radiopaque dyes
Inforn pt about possible burning sensation along the vessel
NPO postmidnight before the test
Instruct client to void immediately before the procedure
Shave injection sites as prescribed
Assess & mark the peripheral pulses

RENAL ANGIOGRAPHY
NURSING CARE ( POST TEST)
Assess V/S & peripheral pulses
Provide bedrest & use of sandbag @ the insertion site
for 4-8 hrs
NPO postmidnight before the test
Assess color & temp of the involved extremity
Force fluids unless C/I
Monitor urinary output
Cystography
Evaluating reflux of bladder to ureters or bladder
injury
Contrast agent is used

Voiding Cystourethrography
Fluoroscopy to visualize lower urinary tract and
assess urine storage in the bladder
Evaluate relfux
Catheter is inserted and contrast is instilled;catheter
is removed when urge to void ;and the patient voids


Diagnostics
Retrograde Pyelography
Catheters are advanced through the ureters into
the renal pelvis by cystoscopy
Contrast agent
Complications
Infection
Hematuria
Perforation of ureter




Diagnostics
Nuclear scans
Injection of radioisotope (iodine 123)
Provides information about kidney perfusion,
function and GFR




Diagnostics
Renal Arteriogram
Catheter is threaded through the axilla or
femoral artery to visualize renal blood vessles

Renal Biopsy
Percutaneous needle biopsy to evaluate renal
disease by obtaining a specimen (rarely done
if client has only one kidney)
Diagnostics
COMMON HEALTH
PROBLEMS
I. URINARY TRACT
DISORDERS
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Urinary Tract Infection (UTI)
Classifications:
1. Upper UTIs are known as Pylonephritis.
- inflammation of renal pelvis
2. lower UTIs:
a. Ureteritis.
b. Cystitis.
c. Urethritis.
Women develop UTI more than men because
their shorter urethras.

CYSTITIS
Cystitis is an inflammation of the urinary bladder.
The most common route of infection is transurethral, often
from fecal contamination, ureterovesical reflux, or the use of
a catheter or cystoscope.

Bacteria may enter the urinary tract in three
ways:
A. by the transurethral route (ascending infection),
B. through the bloodstream (hematogenous spread),
C. by means of a fistula from the intestine (direct extension)
E.Coli accounts for 54% of UTIs
Cystitis occurs more often in women, particularly sexually
active women. Cystitis in men is secondary to some other
factor (eg, infected prostate, epididymitis, or bladder stones).
CLINICAL MANIFESTATIONS
Urgency, frequency, burning, and pain on
urination.
Nocturia, incontinence, and back, suprapubic,
or pelvic pain.
Hematuria
With complicated UTIs (eg, patients with
indwelling catheters), symptoms can range from
asymptomatic bacteruria to a Gram-negative
sepsis with shock
Assessment and Diagnostic
Methods
Urine cultures, colony counts, cellular studies
Leukocyte esterase test and nitrite testing
Tests for sexually transmitted diseases
(STDs)
CT scans and transrectal ultrasonography;
cystourethroscopy may be indicated to
visualize the ureters or to detect strictures,
calculi, or tumors

Gerontologic Considerations
Elderly patients often lack the typical
symptoms of UTI and sepsis.
Nonspecific symptoms, such as altered
sensorium, lethargy, anorexia, new
incontinence, hyperventilation, and low-grade
fever may be the only clues to UTIs in these
patients.
Medical Management
Management of UTIs typically involves
pharmacologic therapy and patient
education.
The nurse teaches the client about the
prescribed medication and infection
prevention measures.
Acute Pharmacologic Therapy
Ideal treatment is an antibacterial agent that
eradicates bacteria from the urinary tract with minimal
effects on fecal and vaginal flora.

Medications may include Cephalexin (Keflex),
Cotrimoxazole (TMP-SMZ, Bactrim Septra)
Nitrofurantoin (Macrodantin Furadantin), ciprofloxacin
(Cipro), levofloxacin(Levaquin), and Phenazopyridine
(Pyridium)

Occasionally, ampicillin or amoxicillin (but
Escherichia coli has developed resistance to these
agents).

Long-Term Pharmacologic
Therapy
About 20% of women treated for
uncomplicated UTIs experience a recurrence.
Recurrence in men is usually due to
persistence of the same organism; further
evaluation and treatment are indicated.
Reinfection of women with new bacteria is
more common than persistence of the initial
bacteria
NURSING PROCESS
THE PATIENT WITH UTI
Assessment

Take careful history of urinary signs and symptoms.
Assess for pain and urinary frequency, urgency, and
hesitancy and changes in urine
Determine usual pattern of voiding to detect factors
that may predispose patient to infection.
Assess for infrequent emptying of the bladder,
association of symptoms of UTIs with sexual
intercourse, contraceptive practices, and personal
hygiene.
Check urine for volume, color, concentration,
cloudiness, and odor.
Nursing Diagnoses

Acute pain related to infection within the
urinary tract
Deficient knowledge related to factors
predisposing to infection and recurrence,
detection and prevention of recurrence, and
pharmacologic therapy
Collaborative Problems/Potential
Complications

Sepsis
Renal failure, which may occur as
the long-term result of either an
extensive infective or inflammatory
process
Planning and Goals
Goals of the patient may include relief of pain
and discomfort, increased knowledge of
preventive measures and treatment
modalities, and absence of complications.
Nursing Interventions
Relieving Pain

Use antispasmodic drugs to relieve bladder irritability and
pain.
Relieve pain and spasm with analgesic agents and heat to
the perineum.
Encourage patient to drink liberal amounts of fluid (water
is best).
Instruct patient to avoid urinary tract irritants (eg, coffee,
tea, citrus, spices, colas, alcohol).
Encourage frequent voiding (every 2 to 3 hours)
Monitoring and Managing Complications

Recognize and teach patient to recognize the signs and
symptoms of UTIs early; initiate prompt treatment.
Manage UTIs with appropriate antimicrobial therapy, liberal fluids,
frequent voiding, and hygiene measures.
Instruct patient to notify physician if fatigue, nausea,
vomiting, or pruritus occurs.
Provide for periodic monitoring of renal function and
evaluation for strictures, obstructions, or stones.
Avoid indwelling catheters if possible; remove at earliest
opportunity. Use strict aseptic technique if an indwelling
catheter is necessary.
Check vital signs and level of consciousness for impending sepsis.
Report positive blood cultures and elevated WBC counts.

Nursing Interventions
TEACHING PATIENTS SELF-CARE

Teach patient health-related behaviors that help
prevent recurrent UTIs, including practicing careful
personal hygiene, increasing fluid intake to promote
voiding and dilution of urine, urinating regularly and
more frequently, and adhering to the therapeutic
regimen.

Teaching should meet the patients individual needs
144
Prevention:

Avoid products that may irritate the urethra (e.g.,
bubble bath, scented feminine products).
Cleanse the genital area before sexual intercourse.
Change soiled diapers in infants and toddlers promptly.
Drink plenty of water to remove bacteria from the
urinary tract.
Do not routinely resist the urge to urinate.
Take showers instead of baths.
Urinate after sexual intercourse.
Women and girls should wipe from front to back after
voiding to prevent contaminating the urethra with bacteria
from the anal area
Expected Patient Outcomes

Experiences relief of pain
Explains UTIs and their treatment
Experiences no complications
2. URINARY CALCULI/
UROLITHIASIS

Kidney Stones
Renal Calculi
URINARY CALCULI/ Urolithiasis

Urolithiasis refers to stones (calculi) in the urinary tract.
Stones are formed in the urinary tract when the urinary
concentration of substances such as calcium oxalate,
calcium phosphate, and uric acid increases.
Stones vary in size from minute granular deposits to the
size of an orange.
Factors that favor formation of stones include infection,
urinary stasis, and periods of immobility, all of which slow
renal drainage and alter calcium metabolism.
The problem occurs predominantly in the third to fifth
decades and affects men more often than women.
GENERAL INFORMATION

Frequent compositions of stones:
- calcium (phosphate), calcium oxalate, uric acid and cystine (rare)
stones
Most often occurs in men age 20-55 years; more common in the
summer

PREDISPOSING FACTORS
Diet: large amount of calcium, oxalate
Increased uric acid levels
Sedentary lifestyles, immobility
Family history of gout or calculi
Hyperparathyroidism
Types of Calculi
Clinical Manifestations

Manifestations depend on the presence of
obstruction, infection, and edema. Symptoms
range from mild to excruciating pain and
discomfort.
Stones in Renal Pelvis
Intense, deep ache in costovertebral region
Hematuria and pyuria
Pain that radiates anteriorly and downward
toward bladder in female and toward testes in
male
Acute pain, nausea, vomiting, costovertebral
area tenderness (renal colic)
Abdominal discomfort, diarrhea
Stones in Renal Pelvis
Ureteral Colic (Stones Lodged in Ureter)

Acute, excruciating, colicky, wavelike pain,
radiating down the thigh to the genitalia

Frequent desire to void, but little urine
passed; usually contains blood because of
the abrasive action of the stone (known as
ureteral colic)
Ureteral Stones
Stones Lodged in Bladder

Symptoms of irritation associated with urinary
tract infection and hematuria
Urinary retention, if stone obstructs bladder
neck
Possible urosepsis if infection is present with
stone
Assessment and Diagnostic Methods

Diagnosis is confirmed by x-rays of the
kidneys, ureters, and bladder (KUB) or by
ultrasonography, IV urography, or retrograde
pyelography.
Blood chemistries and a 24-hour urine test for
measurement of calcium, uric acid,
creatinine, sodium, pH, and total volume.
Chemical analysis is performed to determine
stone composition
Medical Management

Basic goals are to eradicate the stone,
determine the stone type, prevent nephron
destruction, control infection, and relieve any
obstruction that may be present.
Pharmacologic and Nutritional Therapy

Opioid analgesic agents (to prevent shock and syncope) and
nonsteroidal anti-inflammatory drugs (NSAIDs).
Increased fluid intake to assist in stone passage, unless
patient is vomiting; patients with renal stones should drink
eight to ten 8-oz glasses of water daily or have IV fluids
prescribed to keep the urine dilute .
For calcium stones: reduced dietary protein and sodium
intake; liberal fluid intake; medications to acidify urine, such
as ammonium chloride and thiazide diuretics if parathormone
production is increased.
For uric stones: low-purine and limited protein diet; allopurinol
(Zyloprim).
For cystine stones: low-protein diet; alkalinization of
urine; increased fluids.
Bacteria causing a urinary tract infection or bacterial
contamination will produce alkaline urine.
A diet rich in citrus fruits, most vegetables, and
legumes will keep the urine alkaline
For oxalate stones: dilute urine; limited oxalate intake
(spinach, strawberries, rhubarb, chocolate, tea,
peanuts, and wheat bran).
Pharmacologic and Nutritional Therapy

DIET MODIFIED/STONE
CALCIUM STONES
Low calcium diet ( 400 mg daily)
Achieved by eliminating milk/dairy products
Provide acid-ash diet to acidify urine
- Cranberry or prune juice
- Meat
- Eggs
- Poultry
- Fish
- Grapes
- Whole grains
- Take vitamin A & C, Folic acid supplements and Riboflavin
Renal Calculi

DIET MODIFIED/STONE
OXALATE STONES
Avoid excess intake of foods/fluids high in oxalate
- Tea
- Chocolate
- Rhubarb
- Spinach
Maintain alkaline-ash diet to alkalinize urine
- Milk
- Vegetables
- Fruits except prunes, cranberries and plums
Renal Calculi
DIET MODIFIED/STONE

URIC ACID STONES
Uric acid is a metabolic product of purines

Reduce foods high in purine
- Liver, brains, kidneys, venison, shellfish, meat soups, gravies,
legumes and whole grains

Maintain alkaline urine
- Alkaline-ash diet
Renal Calculi
DIET MODIFIED/STONE
CYSTINE STONES (rare)
Low methionine
- Methionine is the essential amino acid from which the non-
essential amino acid cystine is formed

Limit protein foods
- Meat, milk, eggs, cheese

Maintain alkaline-ash diet
Renal Calculi
Stone Removal Procedures

Ureteroscopy: stones fragmented with use of laser,
electrohydraulic lithotripsy, or ultrasound and then
removed.
Extracorporeal shock wave lithotripsy (ESWL).
Percutaneous nephrostomy; endourologic methods.
Electrohydraulic lithotripsy.
Chemolysis (stone dissolution): alternative for those who
are poor risks for other therapies, refuse other methods,
or have easily dissolved stones
Surgical removal is performed in only 1% to 2% of
patients

1. SURGERY
A. PERCUTANEOUS NEPHROSTOMY
- Tube is inserted through skin and underlying tissues into
renal pelvis to remove calculi.

B. PERCUTANEOUS NEPHROLITHOTOMY
- Delivers U/S waves thorough a probe placed on the calculus

2. PERCUTANEOUS ULTRASONIC LITHOTRIPSY (PUL)
- Nephroscope is inserted through skin into kidney. -
Ultrasonic waves disintegrate stones that are then removed by
suction and irrigation.
MEDICAL MANAGEMENT

3. EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY
(ESWL)

- Client is placed in water and exposed to shock waves
that disintegrate stones so that they can be
passed with urine.

- This procedure is non-invasive.


Lithotripsy
NURSING PROCESS
THE PATIENT WITH KIDNEY
STONES
Assessment

Assess for pain and discomfort, including severity, location, and
radiation of pain.
Assess for associated symptoms, including nausea, vomiting,
diarrhea, and abdominal distention.
Observe for signs of urinary tract infection (chills, fever,
frequency, and hesitancy) and obstruction (frequent urination of
small amounts, oliguria, or anuria).
Observe urine for blood; strain for stones or gravel.
Focus history on factors that predispose patient to urinary
tract stones or that may have precipitated current episode
of renal or ureteral colic.
Assess patients knowledge about renal stones and measures to
prevent recurrence.
Nursing Diagnoses

Acute pain related to inflammation,
obstruction, and abrasion of the urinary tract

Deficient knowledge regarding prevention of
recurrence of renal stones
Collaborative Problems/Potential Complications

Infection and urosepsis (from urinary tract
infection and pyelonephritis)

Obstruction of the urinary tract by a stone or
edema, with subsequent acute renal failure
Planning and Goals

Major goals may include relief of pain and
discomfort, prevention of recurrence of renal
stones, and absence of complications.
Nursing Interventions

Relieving Pain

Administer opioid analgesics (IV or
intramuscular) with IV NSAID as prescribed.
Encourage and assist patient to assume a
position of comfort.
Assist patient to ambulate to obtain some
pain relief.
Monitor pain closely and report promptly
increases in severity
Nursing Interventions
Monitoring and Managing Complications

Encourage increased fluid intake and ambulation.
Begin IV fluids if patient cannot take adequate oral fluids.
Monitor total urine output and patterns of voiding.
Encourage ambulation as a means of moving the stone
through the urinary tract.
Strain urine through gauze.
Crush any blood clots passed in urine, and inspect sides
of urinal and bedpan for clinging stones
Instruct patient to report decreased urine
volume, bloody or cloudy urine, fever, and
pain.
Instruct patient to report any increase in pain.
Monitor vital signs for early indications of
infection; infections should be treated with the
appropriate antibiotic agent before efforts are
made to dissolve the stone
Nursing Interventions
TEACHING PATIENTS SELF-CARE

Explain causes of kidney stones and ways to prevent
recurrence.
Encourage patient to follow a regimen to avoid further
stone formation, including maintaining a high fluid intake.
Encourage patient to drink enough to excrete 3,000 to
4,000 mL of urine every 24 hours.
Recommend that patient have urine cultures every 1 to 2
months the first year and periodically thereafter.
Recommend that recurrent urinary infection be treated
vigorously.
Encourage increased mobility whenever possible;
discouage excessive ingestion of vitamins (especially
vitamin D) and minerals.
If patient had surgery, instruct about the signs and
symptoms of complications that need to be reported
to the
physician; emphasize the importance of follow-up to
assess kidney function and to ensure the eradication
or removal of all kidney stones to the patient and
family.
TEACHING PATIENTS SELF-CARE

If patient had ESWL, encourage patient to increase fluid
intake to assist in the passage of stone fragments; inform
the patient to expect hematuria and possibly a bruise on
the treated side of the back; instruct patient to check his or
her temperature daily and notify the physician if the
temperature is greater than 38C (about 101F), or the pain
is unrelieved by the prescribed medication.

Provide instructions for any necessary home care and
follow-up.

TEACHING PATIENTS SELF-CARE

PROVIDING HOME AND FOLLOW-
UP CARE AFTER ESWL
Instruct patient to increase fluid intake to assist passage of
stone fragments (may take 6 weeks to several months
after procedure).
Instruct patient about signs and symptoms of
complications: fever, decreasing urinary output, and pain.
Inform patient that hematuria is anticipated but should
subside in 24 hours.
Give appropriate dietary instructions based on
composition of stones.
Encourage regimen to avoid further stone formation;
advise patient to adhere to prescribed diet.
Teach patient to take sufficient fluids in the evening to
prevent urine from becoming too concentrated at night.
3. URINARY TRACT TUMOR/
BLADDER CANCER
May be benign or malignant: Common
sites of metastasis include bone, lungs,
liver, spleen or other kidney.
Obstructive Disorder:
Urinary Bladder Tumors

Renal Tumors

CANCER OF THE BLADDER
Cancer of the urinary bladder is more common in people
older than 55 years, affects men more often than women
(4:1), and is more common in Caucasians than in African
Americans.
Bladder tumors usually arise at the base of the bladder
and involve the ureteral orifices and bladder neck.
Tobacco use continues to be a leading risk factor for all uri
nary tract cancers. People who smoke develop bladder
cancer twice as often as those who do not smoke.
Cancers arising from the prostate, colon, and rectum in
males and from the lower gynecologic tract in females
may metastasize to the bladder.

Cancer of the Bladder
Clinical Manifestations
Visible, painless hematuria is the most
common symptom.
Infection of the urinary tract is common and
produces frequency and urgency.
Any alteration in voiding or change in the
urine is indicative.
Pelvic or back pain may occur with
metastasis.
Assessment and Diagnostic Methods

Biopsies of the tumor and adjacent mucosa are definitive,
but the following procedures are also used:
Cystoscopy (the mainstay of diagnosis)
Excretory urography
CT scan
Ultrasonography
Bimanual examination under anesthesia
Cytologic examination of fresh urine and saline bladder
washings
Medical Management
Treatment of bladder cancer depends on the
grade of tumor, the stage of tumor growth,
and the multicentricity of the tumor.
Age and physical, mental, and emotional
status are considered in determining
treatment.
Surgical Management
Transurethral resection (TUR) or fulguration for simple
papillomas with intravesical bacille CalmetteGuri (BCG)
is the treatment of choice.
Monitoring of benign papillomas with cytology and
cystoscopy periodically for the rest of patients life.
Simple cystectomy or radical cystectomy for invasive or
multifocal bladder cancer.
Trimodal therapy (TUR, radiation, and chemotherapy) to
avoid cystectomy remains investigational in the United
States.
SURGICAL MANAGEMENT:
Radical nephrectomy: Removal of the entire
kidney, adjacent adrenal gland & renal artery
& vein.

Radiation therapy & chemotherapy.

Surgery
cystectomy - removal of bladder
ileal conduit - creation of urinary diversion
portion of ilium from small intestine is formed into
a pouch the end brought to skin surface to form a
stoma
wears a pouch, empty frequently
good skin care
urine has mucous flecks
SURGICAL MANAGEMENT:
Stoma for ileal conduit
Pharmacologic Therapy
Chemotherapy with a combination of
methotrexate (Rheumatrex), 5-fluorouracil (5-
FU), vinblastine (Velban), doxorubicin
(Adriamycin), and cisplatin (Platinol) has
been effective in producing partial remission
of transitional cell carcinoma of the bladder in
some patients.
Intravesical BCG (effective with superficial
transitional cell carcinoma)
RADIATION THERAPY
Radiation of tumor preoperatively to reduce
microextension and viability
Hydrostatic therapy: for advanced bladder cancer or
patients with intractable hematuria (after radiation
therapy)
Formalin, phenol, or silver nitrate instillations to achieve
relief of hematuria and strangury (slow and painful
discharge of urine) in some patients
Implementation: Monitor abdomen for
distention caused by bleeding
Observe bed linens under the client for
bleeding
Monitor for hypotension, decreases in
urinary output & alterations in LOC,
indicating hemorrhage.
Monitor urinary ouput
Do not irrigate or manipulate the
nephrostomy tube if in place.

4. URINARY RETENTION
201
IV. URINARY RETENTION

Urinary retention is the inability to empty the
bladder completely during attempts to void.
Chronic urine retention often leads to overflow
incontinence (from the pressure of the retained
urine in the bladder).
Residual urine is urine that remains in the
bladder after voiding.
In a healthy adult younger than age 60, complete
bladder emptying should occur with each voiding.
In adults older than age 60, 50 to 100 mL of
residual urine may remain after each void
because of the decreased contractility of the
detrusor muscle.

Distended Bladder

203
URINARY RETENTION
Urinary retention can occur postoperatively in
any patient, particularly if the surgery affected
the perineal or anal regions and resulted in
reflex spasm of the sphincters.
General anesthesia reduces bladder muscle
innervation and suppresses the urge to void,
impeding bladder emptying


204
Pathophysiology

Urinary retention may result from:
diabetes
prostatic enlargement
urethral pathology (infection, tumor, calculus)
trauma (pelvic injuries)
pregnancy,
neurologic disorders such as cerebrovascular
accident, spinal cord injury, multiple sclerosis,
or Parkinsons disease.
Some medications cause urinary retention,
either by inhibiting bladder contractility or by
increasing bladder outlet resistance.
205
Pathophysiology

Medications that cause retention:
anticholinergic agents (atropine sulfate, dicyclomine
hydrochloride [Antispas, Bentyl]), antispasmodic
agents (oxybutynin chloride [Ditropan], belladonna,
and opioid suppositories), and tricyclic antidepressant
medications (imipramine [Tofranil], doxepin
[Sinequan]).
alpha-adrenergic agents (ephedrine sulfate,
pseudoephedrine), beta adrenergic blockers
(propranolol), and estrogens.



206
Assessment and Diagnostic Findings

The assessment of a patient for urinary retention is
multifaceted because the signs and symptoms may
be easily overlooked. The following questions serve
as a guide in assessment:

What was the time of the last voiding, and how much
urine was excreted?
Is the patient voiding small amounts of urine
frequently?
Is the patient dribbling urine?
Does the patient complain of pain or discomfort in the
lower abdomen? (Discomfort may be relatively mild if
the bladder distends slowly.)

207
Does percussion of the suprapubic region elicit
dullness (possibly indicating urine retention and a
distended bladder)?
Are other indicators of urinary retention present, such
as restlessness and agitation?
Does a postvoid bladder ultrasound test reveal
residual urine?

Urinary Retention -
Manifestations
Overflow voiding
Incontinence
Firm, distended bladder

208
209
Complications

Urine retention can lead to chronic infection.
Infections that are unresolved predispose the
patient to calculi, pyelonephritis, and sepsis.
The kidney may also eventually deteriorate if
large volumes of urine are retained, causing
backward pressure on the upper urinary tract.
In addition, urine leakage can lead to perineal
skin breakdown, especially if regular hygiene
measures are neglected.

Urinary Retention - Surgery
Surgery (removal of obstuction, resection of
prostate)
Catheterization after surgery helps prevent
overdistention

210
Nursing Interventions to Encourage
Normal Urinary Elimination
Interventions to maintain normal urinary
elimination include:
Maintain an adequate fluid intake.
Promote normal voiding habits.
Fluid Intake
Increasing fluid intake increases urine
production.
A normal, average daily intake of 1200 to
1500 ml of fluids is adequate for most
patients.
Dilute urine helps prevent urinary tract stones
and infection.
Fluid Intake
Immobilized patients may require fluid intakes
of 2000 to 3000 ml per day to prevent calculi
formation.
Limited fluid intakes may be necessary for
patients on fluid restrictions such as those
with renal impairment or congestive heart
failure.
Fluid Intake
Fluid intake can also be increased by
encouraging the patient to eat plenty of raw
fruits and vegetables, which have a high
water content.
Voiding Habits
Hospital routines and
prescribed medical
therapies can interfere
with a patients normal
voiding habits.
Assist patient with
bedpans or with getting to
the bedside commode or
toilet, if needed.
5. URINARY INCONTINENCE
Urinary Incontinence
The involuntary loss of urine from the
bladder.
May be a complication of urinary tract
problems or neurologic disorders and may be
permanent or temporary.
Nsg Measures:
Minimize embarrassment; provide privacy
Wash, dry, & inspect skin
Prevent decubitus ulcers
Provide bladder training

219
Although urinary incontinence is commonly
regarded as a condition that occurs in older
multiparous women, it is also common in
young nulliparous women, especially during
vigorous high-impact activity.

Age, gender, and number of vaginal
deliveries are established risk factors.
220
221
Clinical Manifestations:
Types of Incontinence

A. Stress incontinence
- is the involuntary loss of urine through an intact
urethra as a result of a sudden increase in intra-
abdominal pressure (sneezing, coughing, or
changing position).
- It predominately affects women who have had
vaginal deliveries and is thought to be the result of
decreasing ligament and pelvic floor support of the
urethra and decreasing or absent estrogen levels
within the urethral walls and bladder base.
In men, stress incontinence is often experienced
after a radical prostatectomy for prostate cancer
because of the loss of urethral compression that the
prostate had supplied before the surgery, and
possibly bladder wall irritability

222
B. Urge incontinence
is the involuntary loss of urine associated with
a strong urge to void that cannot be
suppressed.
The patient is aware of the need to void but is
unable to reach a toilet in time.
An uninhibited detrusor contraction is the
precipitating factor. This can occur in a
patient with neurologic dysfunction that
impairs inhibition of bladder contraction or in
a patient without overt neurologic dysfunction

223
224
C. Reflex incontinence

is the involuntary loss of urine due to
hyperreflexia in the absence of normal
sensations usually associated with voiding.

This commonly occurs in patients with spinal
cord injury because they have neither
neurologically mediated motor control of the
detrusor nor sensory awareness of the need
to void.


225
D. Overflow incontinence
- is the involuntary loss of urine associated
with overdistention of the bladder.
- Such overdistention results from the
bladders inability to empty normally,
despite frequent urine loss.
- Both neurologic abnormalities (eg, spinal
cord lesions) and factors that obstruct the
outflow of urine (eg, tumors, strictures, and
prostatic hyperplasia) can cause overflow
incontinence

Other Classifications of Incontinence

E. Total incontinence: when no urine can be retained in
the bladder, usually due to neurologic problem.

F. Nocturnal Enuresis: incontinence that occurs during
sleep.

227
Medical Management

BEHAVIORAL THERAPY
Behavioral therapies are always the first
choice to decrease or eliminate urinary
incontinence. In using these techniques,
clinicians help patients avoid potential
adverse effects of pharmacologic or surgical
interventions

PHARMACOLOGIC THERAPY
Pharmacologic therapy works best when used
as an adjunct to behavioral interventions.
Anticholinergic agents (oxybutynin


228
MEDICATIONS:
[Ditropan], dicyclomine [Antispas]) inhibit bladder
contraction and are considered first-line medications for
urge incontinence. Several tricyclic antidepressant
medications (imipramine, doxepin, desipramine, and
nortriptyline) also decrease bladder contractions as well
as increase bladder neck resistance. Stress incontinence
may be treated using pseudoephedrine (eg, Sudafed).

Estrogen (taken orally, transdermally, or topically) has
been shown to be beneficial for all types of urinary
incontinence. Estrogen decreases obstruction to urine
flow by restoring the mucosal, vascular, and muscular
integrity of the urethra.

229
SURGICAL MANAGEMENT
Surgical correction may be indicated in
patients who have not achieved continence
using behavioral and pharmacologic therapy.

Most procedures involve lifting and stabilizing
the bladder or urethra to restore the normal
urethrovesical angle or to lengthen the
urethra.

Women with stress incontinence may have an
anterior vaginal repair, retropubic suspension,
or needle suspension to reposition the
urethra.

10/15/2014 Miss Iman Shaweesh 230
231
Nursing Management

For behavioral therapy to be effective, the nurse must
provide support and encouragemen to because it is
easy for the patient to become discouraged if therapy
does not quickly improve the level of continence.

Patient teaching regarding the bladder program is
important and should be provided verbally and in
writing.

The patient is assisted to develop and use a log or
diary to record timing of Kegel exercises, changes in
bladder function with treatment, and episodes of
incontinence.

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6. NEUROGENIC BLADDER
234
NEUROGENIC BLADDER

is a dysfunction that results from a lesion of
the nervous system.
It may be caused by spinal cord injury, spinal
tumor, herniated vertebral disk, multiple
sclerosis, congenital anomalies (spina bifida
or myelomeningocele), infection, or diabetes
mellitus.

235
Assessment and Diagnostic Findings

Evaluation for neurogenic bladder involves
measurement of fluid intake, urine output, and
residual urine volume; urinalysis; and assessment of
sensory awareness of bladder fullness and degree of
motor control.
Comprehensive urodynamic studies are also
performed.

236
Complications

The most common complication of neurogenic
bladder is infection resulting from urinary stasis and
catheterization.
Urolithiasis (stones in the urinary tract) may develop
from urinary stasis, infection, or demineralization of
bone from prolonged immobilization.
Renal failure can also occur from vesicoureteral
reflux (backward flow of retained urine from the
bladder into the ureters) with eventual
hydronephrosis (dilation of the pelvis of the kidney
resulting from obstruction to the flow of urine) and
atrophy of the kidney.
Indeed, renal failure is the major cause of death of
patients with neurologic impairment of the bladder.


237
Medical Management

There are several long-term objectives appropriate
for all types of neurogenic bladders:
Preventing overdistention of the bladder
Emptying the bladder regularly and completely
Maintaining urine sterility with no stone
formation
Maintaining adequate bladder capacity with no
reflux


238
Specific interventions include continuous, intermittent, or
self-catheterization, use of an external condom-type
catheter, a diet low in calcium (to prevent calculi), and
encouragement of mobility and ambulation.

A liberal fluid intake is encouraged to reduce the urinary
bacterial count, reduce stasis, decrease the concentration of
calcium in the urine, and minimize the precipitation of urinary
crystals and subsequent stone formation.

To further enhance bladder emptying of a flaccid bladder,
the individual may try double voiding. After each voiding,
the individual remains on the toilet, relaxes for 1 to 2
minutes, and then attempts to void again in an effort to
further empty the bladder. This can be effective in patients
with disorders characterized by neurogenic bladder (eg,
multiple sclerosis)

Medical Management

239
PHARMACOLOGIC THERAPY
Parasympathomimetic medications, such as
bethanechol (Urecholine), may help to increase the
contraction of the detrusor muscle.

SURGICAL MANAGEMENT
In some cases, surgery may be carried out to correct
bladder neck contractures or vesicoureteral reflux or
to perform some type of urinary diversion procedure.

II. KIDNEY DISORDERS
A. GLOMERULAR DISORDERS
1. GLOMERULONEPHRITIS
Glomerulonephritis
These diseases involving the glomerulus are the
leading cause of chronic kidney disease
Filtration which is the first step in urine formation
occurs in the glomerulus.
Inflammatory condition that affects the glomerulus.
-Damages the capillary membrane and allows
blood cells and proteins to escape from the vascular
compartment into the filtrate
Can be Acute or chronic.

GENERAL INFORMATION
Immune complex disease resulting from an antigen- antibody
reaction.
Secondary to a beta-hemolytic streptococcal infection
occurring elsewhere in the body.
Occurs more frequently in boys, usually between ages 6-7 years
Usually resolves in about 14 days
Self-limiting
Glomerulonephritis
Fall in GFR activates the renin-angiotensin-
aldosterone system leads to water retention and
hypertension.
Acute glomerulonephritis follows an infection with
group A beta Strep such as strep throat.
Protein complexes from the infection become trapped
in the glomerular membrane causing an inflammatory
response and drawing WBC to the area.
Inflammation damages the glomerular capillary walls
and makes them more porous. Plasma proteins and
blood cells escape into the urine.
Glomerulonephritis
Initiating event
Infection
Chronic dx
Increased
Glomerular
permeability
Decreased
GFR
Glomerular capillary
Membrane
inflammation
Glomerulonephritis
Decreased GFR
Increased
Glomerular
Permeability
Hematuria
Proteinuria
Hypoalbuminemia
Edema
Azotemia
Activation of the
Renin angiotensin-
Aldosterone
System
Na and water ret
Hypertension
Edema
CM- Hematuria, proteinuria, loss of plasma
proteins in the blood which leads to
hypoalbuminemia. Edema follows caused by
reduced osmotic draw within blood vessels.
Glomerular filtration is disrupted, GFR falls
and azotemia occurs.
Azotemia- increased blood levels of
nitrogenous wastes, urea, creatinine.

Glomerulonephritis
Glomerulonephritis
CM- acute develop abruptly, 10-14 days after
the initial infection
Nausea, malaise, arthralgias, proteinuria.
Hypertension and edema (periorbital)more
often in children and young adults, not elderly
Symptoms may subside spontaneously, most
people recover completely, some may
develop chronic glomerulonephritis never
regaining full kidney function.
CLINICAL FINDINGS
History of a precipitating streptoccal infection,
usually URTI or impetigo

Edema, anorexia, lethargy
Hematuria or dark-colored urine
Fever
Hypertension
NURSING CARE
MIO, BP, urine.

Provide client teaching and planning concerning:
- Medication administration
- Prevention of infection
- Signs of renal complications
- Importance of long-term follow-up
Chronic Glomerulonephritis
Result of kidney damage by a systemic disease such as
diabetes.
May occur with no previous kidney disease or apparent cause.
Slow progressive destruction of glomeruli and nephrons.
Kidneys decrease in size and surfaces become granular as
nephrons are destroyed.
Proteinuria.
CM- Develop slowly, renal failure may develop years to decades
after the disease is diagnosed.
Diabetic nephropathy-impairs filtration and elimination. Damage
in 15-20 yrs of diagnosis
Lupus nephritis- hematuria and proteinuria, inflammatory lesions
in the glomerulus. Chronic or acute may progress rapidly.
Diagnostic test
Antistrepolysin (ASO)titer- Identifies antibodies to
group A beta-hemolytic strep.
ESR- erythrocyte sedimantation rate will be elevated
in glomerulonephritis. Indicator of inflammation.
BUN and serum creatinine levels are increased in
kidney disease.
Serum electrolytes- will be elevated in kidney disease
UA- blood and protein in the urine, 24 hour urine and
creatinine
KUB to evaluate kidney size, kidney scan or biopsey.
Nursing Diagnosis
Excess fluid volume related to plasma protein
loss and sodium and water retention.
Risk for infection r/t medication regeime
Risk for imbalanced nutrition: less than body
requirements related to anorexia
Deficient knowledge: Glomerulonephritis
related to lack of information
Anxiety related to prescribed activity
restriction
Dietary Management
Glomerulonephritis
Sodium intake is restricted.
Dietary proteins may be increased when
protein is being lost in the urine/if azotemia is
present dietary protein is restricted.
When protein is restricted complete proteins
such as meat, fish, eggs, soy or poultry
should be given; these supply all the
essential amino acids required for growth and
tissue maintenance.
Glomerulonephritis
Treatment
Medications
Plasma exchange therapy
Dietary management
256
Medical Management
The treatment of ambulatory patients is guided by
symptoms.
If hypertension is present, the blood pressure is
lowered with sodium and water restriction,
antihypertensive agents, or both.
Weight is monitored daily, and diuretic medications
are prescribed to treat fluid overload.
Proteins of high biologic value are provided to
support good nutritional status (dairy products, eggs,
meats).

Urinary tract infections are treated promptly.
Dialysis is considered early in the course of
disease to keep patient in optimal physical
condition, prevent fluid and electrolyte
imbalances, and minimize the risk of
complications of renal failure.
Medical Management
Medications
No specific drug tx for glomerulonephritis.
Glucocorticoids such as prednisone.
Penicillin or other antimicrobials for infection.
Antihypertensives and diuretics to lower BP
and to reduce edema
NSAID for patients with nephrotic syndrome
to reduce inflammation.
Nursing Management
Observe for common fluid and electrolyte disturbances in
renal disease; report changes in fluid and electrolyte
status and in cardiac and neurologic status.
Give emotional support throughout the disease and
treatment course by providing opportunities for patient and
family to verbalize concerns. Answer questions and
discuss options.
Educate patient and family about prescribed treatment
plan and the risk of noncompliance. Explain about need
for follow-up evaluations of blood pressure, urinalysis for
protein and casts, blood for BUN, and creatinine.
If long-term dialysis is needed, teach the
patient and family about the procedure, how
to care for the access site, dietary restrictions,
and other necessary lifestyle modifications.
Remind patient and family of the importance
of participation in health promotion activities,
including health screening.
Instruct patient to inform all health care
providers about the diagnosis of
glomerulonephritis.
Nursing Management
Nursing- Health Promotion
Advise to the effective treatment of streptococcal
infections in all age groups.
Complete the full course of antibiotic therapy to
eradicate the bacteria.
Effectively managing diabetes, treating hypertension
and avoid drugs and substances that are potentially
damaging to the kidneys.
Changes in urine output, rising serum creatinine and
BUN levels should be reported to charge nurse.
Monitor for increased wt, increase in blood pressure
or edema
NEPHROTIC SYNDROME
Nephrotic Syndrome
Nephrotic syndrome is a primary glomerular disease
characterized by proteinuria, hypoalbuminemia, diffuse
edema, high serum cholesterol, and hyperlipidemia.
It is seen in any condition that seriously damages the
glomerular capillary membrane, causing increased
glomerular permeability with loss of protein in the urine.
It occurs with many intrinsic renal diseases and
systemic diseases that cause glomerular damage.
It is not a specific glomerular disease but a constellation
of clinical findings that result from the glomerular
damage.
Autoimmune process leading to structural alteration
of glomerular membrane that results in increased
permeability to plasma proteins, particularly
albumin.

Course of the disease consists of exacerbations and
remissions over a period of months to years.

Commonly affects preschoolers.
- boys more often than girls

Prognosis is good unless edema does not respond to
steroids.
Plasma CHON enter the renal tubule
Excreted in urine
PROTEINURIA
Oncotic pressure
Plasma volume
HYPOVOLEMIA
Release of RENIN & ANGIOTENSIN
Secretion of aldosterone
Reabsorption of H2O & Na in distal tubule
BP
Release of ADH
Reabsorption of
H2O
General shift of
plasma into
interstitial spaces
MASSIVE EDEMA
Clinical Manifestations
Major manifestation is edema. It is usually
soft, pitting, and commonly occurs around the
eyes (periorbital), in dependent areas
(sacrum, ankles, and hands), and in the
abdomen (ascites).
Malaise, headache, irritability.
Assessment and Diagnostic Findings

Protein electrophoresis and
immunoelectrophoresis to determine type of
proteinuria exceeding 3.5 g/day.
Urine may contain increased white blood cells
and granular and epithelial casts
Needle biopsy of the kidney for histologic
examination to confirm diagnosis
MEDICAL MANAGEMENT
Treatment is focused on treating the
underlying disease state causing proteinuria,
slowing progression of chronic kidney
disease (CKD), and relieving symptoms.
Typical treatment includes diuretics for
edema, angiotensin-converting enzyme
(ACE) inhibitors to reduce proteinuria, and
lipid-lowering agents for hyperlipidemia.
MEDICAL MANAGEMENT
Drug therapy
- Corticosteroids
- to resolve edema
- Antibiotics
- for bacterial infections
- Thiazide diuretics
- edematous stage
Bedrest
Diet modification
- High CHON
- Low Na
NURSING CARE
Provide bed rest.
- Conserve energy.
- Find activities for quiet play.
Provide high CHON, low sodium diet during edema phase only.
Maintain skin integrity.
- Dont use Band-Aids.
- Avoid IM injections
- medication is not absorbed in edematous tissue.
Obtain morning urine for CHON studies.
Provide scrotal support.
MIO, V/S and WOD
Administer steroids to suppress autoimmune response as ordered.
Protect from known sources of infection.
B. VASCULAR KIDNEY
DISEASES
Hydronephrosis
An abnormal dilation of the renal pelvis and calyces.
Results from urinary tract obstructions or
vesicoureteral reflux. (backflow of urine from bladder
to ureters)
When urine outflow is obstructed pressure in the
renal pelvis increases and it dilates. The nephrons
and collecting tubules may be damaged thus
affecting kidney function.
CM- Acute renal failure may develop.
Diagnosed by ultrasound or CT scan. Cystoscopy to
identify the cause.
Hydronephrosis
Prompt treatment is vital to preserve kidney
function.
Reestablishing urine flow from the affected
kidney.
Nephrostomy tube, ureteral stent or
indwelling catheter may be required.
Stents- used to keep ureters open and
promote healing, surgery or cystoscopy.
Temporary or longer periods if necessary.
Nursing Care Hydronephrosis
Preventing hydronephrosis and ensuring
urinary drainage.
Monitor intake and output
Monitor bladder emptying to identify impaired
urine outflow. Pelvic or abdominal tumors,
urinary calculi, adhesions and scarring from
previous surgeries or neurologic deficits.


POLYCYSTIC KIDNEY
DISEASE
Polycystic Kidney Disease
Polycystic Kidney Disease
Hereditary disease in which cysts form on the
kidneys, the kidneys enlarge and their
function is gradually destroyed.
Common affects children and adults.
Adult is slow and progressive, CM in 30-40.
Offspring of clients with polycystic kidney
disease have 50% chance of of inheriting the
disorder. Genetic counseling!
CLINICAL MANIFESTATIONS
flank pain
micorscopic or frank hematuria
proteinuria,
polyuria,
nocturia.
UTI and stones are common.
Hypertension and renal failure
DIAGNOSIS
Renal ultrasound.

TREATMENT
Fluids
Ace inhibitors
preserve kidney function avoid UTIs.
Will have renal failure and need dialysis or
kidney transplant.

RENAL FAILURE
Renal Failure
Kidneys are unable to remove accumulated
waste products from the blood.
Acute
Chronic or end stage chronic
Azotemia and fluid and electrolyte and acid-
base imbalances are the defining
characteristics.
ARF
Acute renal failure is a sudden, usually
reversible deterioration in normal renal
function.
Risk factors: Critically ill, major trauma,
surgery, infection, hemorrhage, severe heart
failure, lower urinary tract obstruction.
Acute Renal Failure
It can be classified according to underlying
cause as:
1. Prerenal: Most common results from
conditions that affect the blood supply to the
kidney. Hemorrhage. Shock or heart failure.
a. Hypovolemia.
b. Impaired cardiac efficiency.
c. Vasodilatation.
Acute Renal Failure
2. Intrarenal: damage to the nephrons by
inflammation (acute glomerulonephritis, HTN)
a. Acute nephritis.
b. Antibiotics.
c. NSAIDs.

3. Postrenal obstruction: obstruction of urine
outflow
a. Urinary tract obstruction.
b. Tumors.

PRERENAL CAUSES INTRARENAL
CAUSES
POSTRENAL CAUSES
Calculi
BPH
Tumors
Strictures
Blood clots
Trauma
Anatomic malformation
Hypotension
Acute tubular necrosis (ATN)
Diabetes mellitus
Cardiogenic shock
Acute vasoconstriction Malignant hypertension
Hemorrhage Acute glomerulonephritis
Tumors Burns
Septicemia
Blood transfusion reactions
CHF
Nephrotoxins
Clinical Stages of ARF:
Initiation period: initial insult and oliguria.
Oliguric period (urine volume less than 400
mL/day): Uremic symptoms first appear and
hyperkalemia may develop.
Diuresis period: gradual increase in urine
output signaling beginning of glomerular
filtrations recovery. Laboratory values
stabilize and start to decrease.
Recovery period: improving renal function
(may take 3 to 12 months
CLINICAL FINDINGS
OLIGURIC PHASE
Hypernatremia
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Hypermagnesemia
Metabolic acidosis
DIURETIC PHASE
Hyponatremia
Hypokalemia
Hypovolemia
CONVALESCENT PHASE
Normal Urine Volume
Increase in LOC
BUN stable and normal
May develop CRF
290
Acute Renal Failure
Diagnostic Evaluation:
1. Serum creatinine levelthe most reliable
measure of the GFR, found to be rising
2. Radionuclide studies to evaluate GFR and
renal blood flow and distribution
3. Urinalysisreveals proteinuria, hematuria,
casts
4. Ultrasonography to determine anatomic
abnormalities
291
Acute Renal Failure
Treatment:
1. Correction of any reversible cause of acute
renal failure (ie, surgical relief of obstruction)
2. Correction and control of fluid and electrolyte
imbalances
- 3. Restoration and maintenance of stable vital
signs
- 4. Maintenance of nutrition with low-sodium, low-
potassium, low-phosphate, moderate-protein
diet
- 5. Initiation of dialysis for patients with life-
threatening complications
Chronic Kidney Disease/
Chronic Renal Failure
Progressive, irreversible destruction of the kidneys
that continues until nephrons are replaced by scar
tissue.
Loss of renal function is gradual.
Hypervolemia can occur owing to the inability of the
kidneys to excrete sodium & water, or hypovolemia
can occur owing to inability of the kidneys to
conserve sodium & water
Highest in African Americans.
Diabetes is the leading cause of ESRD,
hypertension, glomerulonephritis.
293
Chronic Renal Failure
Causes:
1. Recurrent UTIs.
2. Toxic agents.
3. Diabetic nephropathy.
4. Uncontrolled hypertension.

CLINICAL FINDINGS
STAGE 1
Diminished Renal
Reserve
STAGE 2
Renal Insufficiency

STAGE 3
End Stage

CRF

STAGE 1 DIMINISHED RENAL RESERVED
Renal function decrease
No accumulation of metabolic wastes
the healthier kidney compensates
Nocturia & polyuria occur as a result of decrease ability to concentrate
urine

STAGE II RENAL INSUFFICIENCY
Metabolic wastes begin to accumulate
oliguria & edema occur as a result of decrease responsiveness to
diuretics

STAGE III END STAGE
Excessive accumulation of metabolic wastes
kidneys are unable to maintain homeostasis
dialysis or other renal replacement treatment is required


Nephrons are destroyed by disease,
those that remain hypertrophy to
compensate for the lost tissue. The
increased demand on these nephrons
increased their risk for damage and
destruction.
Chronic Renal Failure/ CKD
CKD STAGES
The stages of CKD (Chronic Kidney Disease) are mainly based on
measured or estimated GFR (Glomerular Filtration Rate). There are
five stages but kidney function is normal in Stage 1, and minimally
reduced in Stage 2


STAGE GFR DESCRIPTION
1 90+ Normal kidney function
but urine findings or
structural abnormalities
or genetic trait point to
kidney disease
2 60-89 Mildly reduced kidney
function, and other
findings (as for stage 1)
point to kidney disease
CKD STAGES
3A
3B
45-59
30-44
Moderately reduced
kidney function
4 15-29 Severely reduced kidney
function
5 <15 or on dialysis

Very severe,
or endstage kidney
failure (sometimes
callestablished renal
failure)
CLINICAL FINDINGS

Nausea and vomiting Uremic frost
Decreased urinary output Dyspnea
Metabolic Acidosis Azotemia
Hypertension (later) Lethargy
Convulsions Memory impairment
Pericardial friction rub CHF
UREMIC FROST
301
Treatment:

1. Correction of calcium phosphorous
imbalance. Administer activated vitamin D to
increase calcium absorption and calcium
phosphate binders with meals to bind
phosphate in the gastrointestinal tract.
2. Correction of acidosis with buffers such as
Bicitra
3. Diets should meet caloric needs of the child
containing adequate protein for development
(1.01.5 g/kg per day).

302
Treatment:
4. Correction of anemia through the use of
erythropoietin (Epogen) administered
subcutaneously at home
5. Growth retardation should be evaluated for
possible use of growth hormone.
6. Treatment options for end-stage renal
disease are hemodialysis, peritoneal dialysis,
or transplantation.
7. Institute dialysis therapy while transplant
work-up is in progress.
Prevent neurologic complications.
Assess qH for signs of uremia: fatigue, loss of
appetite, decrease U/O, apathy, confusion, HPN,
edema of the face & feet, itchy skin, restlessness &
seizures
Assess for changes in mental functioning
Orient confused client to time, place, date, & persons
Institute safety measures to protect client from falling
out of bed
Monitor serum electrolytes, BUN, & creatinine as
ordered




NURSING CARE:
Promote optimal GI function.
assess/provide care for stomatitis
Monitor N/V & anorexia
Administer antiemetics as ordered
Assess for signs of gi bleeding

NURSING CARE:
Monitor/prevent alteration in F/E
PROMOTE MAINTENANCE OF SKIN
INTEGRITY
Assess/provide care for pruritus
Assess for uremic frost & bathe in plain water
* urea crystallization on the skin

NURSING CARE:
- MONITOR FOR BLEEDING
COMPLICATIONS, & PREVENT INJURY
Monitor Hgb, Hct, platelets, RBC
Hematest all secretions
Administer hematinics as ordered
avoid IM injections

NURSING CARE:

Assess for hyperphosphatemia
- Paresthesias
- Muscle cramps
- Seizures
- Abnormal reflexes
Normal value of phosphate= 2.5-4mg/dl; child= 6mg/dl
Administer Aluminum hydroxide gels as ordered
- Amphogel, AlternaGEL

Potassium= normal =3.5-5mEq/L; >6mEq/L (peak T
waves, widened QRS), metabolic acidocis increase
serum potassium level
administer kayexalate ( sodium polysterene SO4)



Promote/maintain maximal cardiovascular
function.
- Cardiovascular disease is the leading cause
of death in client with chronic kidney disease,
HTN is common.
- Most meds are excreted by the kidneys.
Antihypertensive drugs are used to decrease
BP.
- Lasix and ACE inhibitors.

Provide care for client receiving dialysis.

309
Educating About Chronic Renal Failure

1. Because numerous issues may interfere with the
patient's psychological and social development and
education, help the patient and family to cope with:
a. Uncertainty regarding the course of the disease and
ultimate prognosis.
b. Abnormal lifestyle necessitated by dialysis.
c. Burden of dialysis and continuous administration of
medications.
d. Fear of death, present in most children,
adolescents,
and family members

ESRD
Uremia- nausea, apathy, weakness, fatigue.
Vomiting, lethargy and confusion
Cardiovascular disease is the leading cause
of death in client with chronic kidney disease,
HTN is common.
Most meds are excreted by the kidneys.
Antihypertensive drugs are used to decrease
BP Lasix and ACE inhibitors.
Fluids and sodium intake are restricted. CHO
are increased. TPN may be initiated.
Renal replacement Therapy
Dialysis- Diffusion of solutes across a membrane
from an area of higher concentration to one of lower
concentration.
Used to remove excess fluid and waste products in
renal failure.
Blood is separated from a dialysis solution by a
semipermeable membrane. Water and solutes such
as urea and electrolytes diffuse across this
membrane, but proteins do not.
Dialysis compensates for the kidneys inability to
eliminate excess water and solutes.
2 or 3 sessions per week. Outpatient center.
Dialysis
Hemodialysis- Electrolytes, waste products
and excess water are removed from the body
by diffusion and filtration. The clients blood
is pumped through a dialyzer.
Peritoneal Dialysis- The peritoneum serves
as the dialyzing surface. Warmed dialysate is
instilled into the peritoneal cavity through a
peritoneal catheter.
END