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Flashcards in Week 11 Deck (53):
1

Renal function helps...

Renal function helps maintain the body’s state of homeostasis

2

The function of renal and urinary systems is

Regulating fluid and electrolytes (excretion/re-absorption):
Fluid balance
Acid-base balance
Electrolyte balance
Removing wastes

Providing hormones:
Red blood cell production
Erythropoietin
Bone metabolism
Assists in conversion of Vitamin D to maintain calcium balance
Blood pressure regulation
Renin/Prostaglandins

3

Subjective data - patient assessment

Past medical history and pre-existing conditions: (Diabetes/hypertension/calculi/childbirth/STDs)

Medications (allergies):
potentially nephrotoxic (gentamycin/captopril/NSAIDs/aspirin)
others change urine colour (nitrofurantoin/dantrolene)
increase urine output (diuretics)
alter sphincter function/bladder contraction (Ca. channel blockers/antidepressants/antihistamines)
haematuria (anticoagulants)

Past surgical history/treatments – related to this system
Functional health pattern questions:
Changes in voiding habits/haematuria/pain (dysuria)
Family history

4

Objective data - patient assessment

Physical examination:
Especially abdominal and kidney palpation
Presence of oedema
Bladder percussion
Digital (rectal) prostatic palpation (DRE)
Inspection of genitalia/urinary meatus
Abnormal anatomy (female circumcision/”whistle-cock”)

5

Diagnostic tests for renal and urinary system

Urinalysis - baseline information – 1st am spec.
24 hr urine collection - creatinine/protein/specific components
Empty bladder at designated time
MSU/catheter spec.
Residual urine – left in bladder after urination (< 50-150mls)
Blood tests – specifically creatinine & urea
Radiological – x-rays/IVP/ultrasound/CT Scan/MRI/’scopes
Radionuclide Imaging/biopsy/cystoscopy
Renal function tests

Patient preparation
? Full bladder/? Encourage fluids/? fasting

6

The prostate gland

encircles the urethra just below the neck of the bladder

7

Benign prostatic hyperplasia (BPH)

Proliferation of cells leading to increase in gland size
Occurs in 50% of men over 50 yrs/90% of men over 80 yrs/etc
Depending on lobe affected can gradually compress (and obstruct) urethra

8

Prostate cancer

Malignant tumour affecting 1 in 11 Australian men/kills 20-25% of those diagnosed
Earlier detection leads to better/more successful treatment
Can lead to urinary retention/obstruction
Frequently diagnosed by pain/fracture after it metastasises

9

Clinical manifestations of benign prostatic hyperplasia

Mild to severe
Mild weakening of urinary stream
Frequency
Hesitancy
Dribbling
Incomplete bladder emptying
Retention
Nocturia
Urgency
Dysuria
Incontinence

10

Treatment of benign prostatic hyperplasia

Depends on severity of symptoms/age & condition of pt.
Conservative
“watchful waiting”/dietary changes/bladder training
Medication
anti-androgenics (finasteride)/alpha adrenergic agonists (prazosin)

Surgical :
Microwave thermotherapy/needle ablation
Laser prostatectomy/electrovaporisation
Transurethral resection prostate (TURP) – most common
(open) radical prostatectomy

11

Urinary retention is

Inability of the bladder to empty completely
types: chronic or acute

12

Residual urine is the

Amount of urine left in the bladder after voiding
Generally 100/150 mLs on 1/2/3 occasions

13

Assessment of urinary retention

Subjective – feel “empty” or “full”/dysuria/previous problem

Objective – pt. dribbling/monitor output (“fluid balance”)distension /palpation/percussion/pt. restless or agitated/bladder scan

14

Nursing measures to promote voiding

Set environment (privacy)/running water /baths/warm compresses
Catheterisation may be necessary to prevent bladder overdistension

15

Benign prostatic hyperplasia common surgery is

Trans Urethral Resection of Prostate (TURP)
Under general or spinal anaesthetic
From 15 mins to 2-3 hours depending on size of prostate
Complications minimal (haemorrhage/hyponatraemia/infection)
Post-op - large bore 3 way catheter/bladder washout (BWO)

16

Nursing management for Trans urethral resection of prostate

Preop - ? retention - IDC/UTI – antibiotics/education
Postop
Bladder Washout
Accurate monitoring and measurement of input/output essential

17

Urinary tract infections are classified according to

Lower tract – urethritis/cystitis/prostatitis (dysuria/generally unwell)
Upper – pyelonephritis/interstitial nephritis/renal abscess
Complicated (IDC/obstruction/stone/pregnancy/recurrent)
Uncomplicated – in otherwise normal tract
Initial or recurrent
Unresolved or persistent
Bacteria type

18

Urinary tract sterility is maintained by

Complete emptying of bladder
Antibacterial capabilities of mucosa
Peristaltic actions of urethra
Vesico-ureteric competence (valve/trigone angle/musculature)
Urine acidity (<6.0) and flow

19

Predisposing factors for UTI

Obstruction (stone/stricture/BPH)
Urinary retention/incomplete bladder emptying (high ‘residuals’)
Foreign objects (catheterisation/stents)
Sex/age/immunological/pregnancy/hormonal/hygiene/anatomical
Immunosuppression
Co-morbidities

20

UTI diagnosis

Via urine dipstick test(indication not diagnostic)
MSU
Clinical manifestations

21

UTI - lower urinary tract clinical manifestations

Dysuria
Frequency
Urgency
Nocturia
Weak stream
Dribbling
Hesitancy
Intermittency
Incomplete emptying of bladder
Haematuria

22

UTI - upper urinary tract clinical manifestations

Dysuria
Frequency
Urgency
Nocturia
Weak stream
Dribbling
Hesitancy
Intermittency
Incomplete emptying of bladder
Haematuria
Abdominal/flank/supra-pubic pain
Vomiting/diarrhoea
Fever/chills
Confusion
General malaise

23

UTI - upper and lower urinary tract in older patients clinical manifestations

Confusion/lethargy
Frequency/urgency/dysuria
Anorexia
Low grade febrile episodes

24

Prevention of UTI

Avoid indwelling catheters, aseptic insertion & hygienic care of catheters
Personal hygiene
Void after sex/wipe front to back
Medications as prescribed:
Antibiotics, analgesics, and antispasmodics
Increased fluid intake
Avoid urinary tract irritants such as coffee/tea/citrus/spices/ cola/alcohol
Frequent voiding/reduce urine retention
? Prophylactic cranberry juice
Patient education

25

Treatment of UTI

Antibiotics

Recurrent UTIs:
Prophylactic antibiotics
Investigate abnormalities/treat cause
Cranberry juice(?)
Patient education

26

Renal failure is

partial or complete kidney dysfunction
Leads to accumulation of metabolic wastes
Leads to alteration in fluid/electrolyte and acid-base balance

27

Acute renal failure

Rapid loss of renal function (hours or days)
Decreased GFR & ? oliguria
Reversible (potentially) but high mortality rate
More common in elderly

28

Chronic renal failure

Slow insidious and irreversible
Can have acute on chronic episodes

29

End-stage renal disease

Final, irreversible stage of chronic renal failure

30

Azotaemia is the

accumulation of nitrogenous wastes

31

Uraemia is

symptomatic changes in multiple body systems due to progressive azotaemia

32

Glomerular filtration rate

~ 100 - 120 ml/minute

33

Catabolism is the

breakdown of body proteins

34

Acute renal failure - pre renal

Factors that decrease renal blood flow:
Hypovolaemia (haemorrhage)
Dehydration/nausea & vomiting
Decreased cardiac output (heart failure/MI)
Decreased peripheral vascular resistance (septic shock)
Decreased renal blood flow (renal vein emboli)

35

Acute renal failure - intrarenal

Factors that cause direct damage to the renal parenchyma:
Nephrotoxic injury
(drugs – gentamycin/heavy metals)
Infection (pyelonephritis/glomerulonephritis)
Thrombosis
Toxaemia (pregnancy)
Malignant hypertension
SLE (systemic lupus erythematosus)

36

Acute renal failure - post renal

Mechanical obstruction
BPH
Bladder cancer
Renal calculi
Neuromuscular disorders
Prostate cancer
Spinal cord diseases
Strictures
Trauma

37

Phases of acute renal failure

1. Initiation phase
From time of injury to clinical manifestations evident

2. Oliguric (Maintenance) phase
Notable fall in GFR and tubular damage
Uraemic symptoms and oedema increase/hypertension
Confusion/fatigue/acid-base imbalance/anaemia/ECG changes (hyperkalaemia)

3. Diuretic (maintenance) phase
Glomeruli and tubules still dysfunctional
High urine volume/still severely uraemic with all it’s affects
Dehydration potential

4. Recovery Phase (3 – 12 months)
Glomerular and tubular repair and regeneration
Gradual recovery and improvement in all areas

38

Clinical manifestations of acute renal failure

Potentially evident in every body system
Persistent nausea & vomiting & diarrhoea
Lethargy/general malaise/fatigue
Signs of dehydration (dry mucous membranes/skin)
Uraemic fetor
CNS symptoms
Twitching/drowsiness/headache/seizures
Urine output variable according to the stage of ARF (~20mLs/hr)
ECG changes
Haematuria

39

Diagnosis of acute renal failure

Urinary changes/blood tests/renal function tests/scans

40

Treatment of acute renal failure

Detect & resolve the underlying cause
Treat the clinical manifestations & prevent complications
Nutritional support

Continuous renal replacement therapy (haemodialysis)
Used more frequently for early intervention to prevent complication and recovery

Medications:
IV fluids/volume expanders to improve renal perfusion
Diuretics to increase urine output (decrease fluid overload/washout wastes)
Antihypertensives to decrease blood pressure
NSAIDs/nephrotoxic drugs ceased
Proton-pump inhibitors/other to prevent GI haemorrhage
Calcium resonium to decrease hyperkalaemia (!)
All drug doses need to be titrated carefully as most are excreted through the kidneys

41

Nursing care for acute renal failure

Monitoring:
Vital signs/skin assessment (for dehydration)
Subjective & objective assessment (cardiac/pulmonary function)
Fluid balance monitoring (intake and output) - strict
Previous 24 hrs output + 600mls (insensible loss) - ???
Daily weight/regular oral hygiene
Administer drugs (& monitor for side effects)
Monitor lab. results (frequent)
General nursing care (skin)/bed rest (reduce metabolic rate)
Asepsis
Patient & family support/education

Nutritional (dietician monitored)
Balance bodily requirements with preventing fluid & electrolyte disorders
Daily kilojoules – 125-150kj/kg
Increased carbohydrates to provide energy (& spare protein)
Protein (high in essential amino acids) – 0.6-2.0g/kg (restricted)
Potassium in diet dependant on serum levels (restricted)
Sodium (restricted to decrease oedema)
Phosphate (restricted)

Enteral feeding (TPN – Total Parenteral Nutrition) if unable to eat/drink but will likely require haemodialysis to remove extra fluid
Fluid balance monitoring (intake & output) – strict/daily weight

All fluid and food is measured/weighed/specially prepared

42

Chronic renal failure is the

Result of chronic disease processes with gradual destruction of glomerular filtration and tubular function
Can be as a result of ARF where full recovery not achieved

43

Chronic renal failure management

Preserve existing renal function
Preventing and managing complications
Providing psychological support

Pharmacological:
Complex as many drugs are excreted via the kidneys
Treat underlying cause of CRF and associated conditions
Manage clinical manifestations
Diuretics/antihypertensives/resonium/phosphate binders etc

Nutrition and fluid management:
Nutritional and fluid management in line with ARF

44

Nursing care of chronic renal failure

(Basically as per ARF)
Fluid management
Nutritional management
Full nursing care

Patient self management:
Educate and encourage
Community resources and support groups

Depends on setting – home/regional/tertiary hospital

45

End-stage renal failure

Requires renal replacement therapy
Haemodialysis
Peritoneal dialysis
Kidney transplantation

Either in-hospital or at home

46

Urinary catheterisation diagnosis

Monitoring urine output
Instillation of radio-opaque dye/medications
Obtaining specimens

47

Urinary catheterisation treatment

Obstruction/retention
Post procedure (surgery/childbirth)

48

Urinary catheterisation types

Intermittent/indwelling
Insertion into bladder/ureter/kidney

Ileal diversion (bags)

49

Urinary catheterisation complications

Only if necessary
Bladder scanners instead of residual catheters
UTIs (during insertion/while inserted)
Track for infection
Mucosal irritation
Invasive and embarrassing
Bladder spasms
Urethral false passage/rupture
Urethral strictures
Pressure necrosis
Allergy (most now latex free)

50

Supra-pubic catheterisation

Temporary
Post surgical/Post trauma
Permanent
Urethral destruction
Patient choice (? easier care if paralysed)
Residual urine pre removal (clamp for 4 – 6 hrs/pt attempts to void then unclamp & drain.
2 x successful residual urines under 100/150 - removed)

51

Advantages to supra-pubic catheterisation

Comfort & mobility/less UTI/spont. voiding post removal easier

52

Complications of supra-pubic catheterisation

Encrustaceans/bladder stones/UTIs/presence of wound
Requires more specialised care

53

Nursing management of indwelling (urethral) catheter

Depends on type/indication
Monitor drainage:e
Amount/colour/odour
Fluid balance chart

Secure catheter (an issue of importance):
With traction (if ordered) for tamponade (post TURP bleeding)
Prevent urethral erosion/comfort/accidental removal/leakage
For men – abdomen or upper thigh (varying practice)
For women – upper thigh
Surgical tape or proprietary device (varies)

Monitor for infection