Care of the Patient With Renal and Urinary Disorders Handout

Nursing IV - Medical Surgical Component

Classroom Objectives
Discuss the pathophysiology and clinical manifestations of renal failure Interpret the results of laboratory data & diagnostic tests associated with renal failure. Discuss three treatment modalities used in the collaborative management of chronic renal failure.

Classroom Objectives Cont.

Describe the kidney donor selection process. Discuss the drug therapy used to prevent transplant rejection.

Continued
Use Maslows hierarchy to prioritize assessments in the patient with CRF undergoing various treatment modalities. State four nursing diagnoses (NANDA)commonly associated with a patient in end-stage renal disease.

Classroom Objectives Cont.

List four corresponding nursing outcomes (NOC) associated with the diagnoses generated for the patient in end-stage renal disease. Discuss appropriate NIC based nursing interventions for the patient undergoing dialysis or renal transplant.

Continued
Discuss the nursing management of the end-stage renal patient at home and the use of community resources

Anatomic Location of the Organs of the Renal/Urinary System

Slide 72.1

Bisection of the Kidney Showing Major Structures of the Kidney

Slide 72.4

Anatomy of the Nephron

Sodium and Water Reabsorbtion by the Tubules of a Cortical Nephron

Renal Function
Excretory function- urine formation Regulatory functions acid base balance Renal related endocrine functions

Excretory Function/urine Formation*

Glomerular filtration Tubular Reabsorption - proximal convoluted tubule Tubular secretion Active and passive reabsorption

Regulatory Functions*
Partial control of acid-base balance Renal regulation of water Renal regulation of electrolytes- Na+ & K+

Renal Related Endocrine Functions*

Renin Erythropoietin Prostaglandins Vitamin D/Calcium Insulin

The Juxtaglomerular ComplexRenin

Slide 72.10

Renal Hormone Production and Hormones Influencing Renal Function*

Hormones influencing Renal function Antidiuretic hormone (ADH) Aldosterone Makes DCT and CD permeable to water to maximize reabsorption and produce a Released from concentrated urine posterior pituitary Promotes sodium reabsorption and Released from potassium secretion adrenal cortex in DCT and CD; water and chloride follow sodium movement
DCT = distal convoluted tubule; CD = collecting ducts.

Slide 72.3

Renal Hormone Production and Hormones Influencing Renal bone Function Stimulates marrow to make red
blood cells Promotes absorption of calcium in the gastrointestinal tract Renal Raises blood Activated vitamin D parenchyma pressure as result of angiotensin Renin Juxtaglomerular (vasoconstriction) cells of and aldosterone the afferent and (volume expansion) efferent Prostaglandins secretion arterioles Regulate intrarenal blood flow by vaso Renal tissues Slide 72.2 dilation or constriction
Renal hormone Production Erythropoietin

Renal parenchyma

Assessment of Renal/urinary Problems

Secondary Prevention: Early Detection
history physical signs & symptoms renal system lab tests

Interview Your New Patient

 What questions should you ask regarding symptoms? What risk factors for development of CRF does the new admission have? What cardiac and respiratory manifestations might you find on physical exam?

Very ill new admission - Suspect CRF, 7 lb weight gain in 3 wks, Hx diabetes and HTN

History/diseases RT. Renal

HTN, D.M., SLE Infectious diseases - Strep. UTI Drugs Congenital abnormalities, ie polycystic kidney disease Diet - ca++, higher mineral Immobility

Commonly Used Renal and Urinary Terms*

Oliguria decreased urinary output; Total urinary output between 100 and 400 ml in 24 hr. Polyuria increased urinary output; Total urinary output usually greater than 2000 ml in 24 hr. Azotemia increased BUN and serum creatinine levels- suggestive of renal impair. but without outward symp.of renal failure. Uremia full-blown signs and symptoms of renal failure; Sometimes referred to as the uremic syndrome, especially if cause unknown.

Slide 72.6

Physical Signs & Symptoms of Renal Disease*

Fatigue Change in mentation Headache HTN Change in body weight Pain sharp or dull, localized or diffuse

Clinical Manifestations of CRF*

Cardiovascular Respiratory-sleep apnea, jittery Hematologic Genitourinary Reproductive Gastrointestinal Musculoskeletal- renal osteodystrophy 90% Neurological Integumentary Nutritional Electrolyte Imbalances Metabolic

Blood Chemistries*
BUN -greater than 20mg/dl - renal insufficiency normal =10-20mg/dl. Elderly sl. Higher Creatinine - 0.8 - 1.5 mg/dl Creatinine clearance - best indication of overall renal function- ave. 108- 120ml/min BUN/ Creatinine ratio: 10:1 to 20:1

Acute Renal Failure

Prerenal causes Renal causes Postrenal causes

Medical Management During ARF*

Dialysis Manage secondary infections & Pericarditis Careful fluid replacement Electrolyte replacement High calorie, low protein diet Symptomatic relief - seizures, anemia, bleeding tendencies

Chronic Renal Failure*

Progressive reduction of functioning renal tissue. Remaining kidney can no longer maintain body environment. Insidiously or after ARF. HTN and diabetes - most common causes.

Progression Toward Chronic Renal Failure

Stage I Stage II Stage III

Slide 75.6

Stage I: Diminished Renal Reserve.*

Renal function is reduced, but no accumulation of metabolic wastes occurs. The healthier kidney compensates for the diseased kidney. Ability to concentrate urine is decreased, resulting in nocturia and polyuria. A 24-hour urine for creatinine clearance is necessary to detect that renal reserve is less than normal.

Stage II: renal insufficiency.*

Metabolic wastes begin to accumulate in the blood because the unaffected nephrons can no longer compensate. Responsiveness to diuretics is decreased = oliguria and edema. The degree of insufficiency is determined by decreasing GFR (glomerular filtration rate) and is classified as mild, moderate, or severe.

Treatment is medical.

Stage III: Renal Failure - end-stage renal disease.* Excessive amounts of metabolic wastes such as urea and creatinine accumulate in the blood. The kidneys are unable to maintain homeostasis. Treatment is by dialysis or other renal replacement therapy.

Stage IV End Stage Renal Failure Uremia

Anuria Marked azotemia Severe electrolyte imbalances Pul edema , uremic lung Uremic frost,pruritus Anemia Proteinuria CHF

GFR = Calculation of Age, Serum Creatinine, Race, Sex

Stage 1 90 mL/min or more - Healthy kidneys or Kidney damage with normal or high GFR Stage 2 60 to 89 mL/min -Kidney damage and mild decrease in GFR Stage 3 30 to 59 mL/min - Moderate decrease in GFR Stage 4 15 to 29 mL/min Severe decrease in GFR Stage 5 Less than 15 mL/min or on dialysis Kidney failure

Clinical Manifestations of CRF*

Cardiovascular Respiratory-sleep apnea, jittery Hematologic Genitourinary Reproductive Gastrointestinal Musculoskeletal- renal osteodystrophy 90% Neurological Integumentary Nutritional Electrolyte Imbalances Metabolic

Clinical Manifestations Continued*

Key Features of Uremia- Excessive amounts of Urea & Nitrogenous Wastes ( Azotemia)*
Metallic taste Anorexia Nausea Vomiting Muscle Cramps Itching

Key Features of Uremia Continued*

Fatigue & Lethargy Hiccups Edema Dyspnea Muscle Cramps Parenthesis

Electrolyte Imbalances*N.B!
K+ increases Phosphate increases Sodium - normal or decreased Magnesium increases Calcium decreases Metabolic acidosis

The Effects of Renal Failure on Phosphate and Calcium Balance

Slide 75.1

Focused Assessment for Care Clients with Chronic Renal Failure (Acute Care Too)*
Assess renal status, including Amount, frequency, and appearance of urine (anuric clients) Presence of bone pain Presence of hyperglycemia secondary to diabetes

Slide 75.19

Focused Assessment for Care Clients with Chronic Renal Failure*

Assess cardiovascular and respiratory status, including Vital signs, with special attention to blood pressure Presence of S3 and/or pericardial friction rub Presence of chest pain

Slide 75.18

Assessment Continued*
Presence of edema (periorbital, pretibial, sacral) Jugular vein distension Presence of dyspnea Presence of crackles, beginning at the bases, and extending upward

Continued*
Assess hematologic status, including Presence of petechiae, purpura, ecchymoses Presence of fatigue or shortness of breath Assess gastrointestinal status, including Presence of stomatitis Presence of melena

Assessment Continued*
Assess integumentary status, including Skin integrity Presence of pruritis Presence of skin discoloration

Review - Focused Assessment for Clients with Chronic Renal Failure

Assess NEUROLOGIC status, including Changes in mental status Presence of seizure activity Presence of sensory changes Presence of lower extremity weakness

Assess NUTRITIONAL status, including

Weight gain or loss Presence of anorexia, nausea, or vomiting

Case Study-End Stage Renal Disease

NURSING DIAGNOSES CRF

Nursing Diagnoses for CRF Patient*

Fluid Vol. deficit of Fluid Vol Excess rt. impaired Renal function Altered Nutrition less than Body Requirements rt anorexia, nausea Fatigue rt. anemia & altered metabolic state Risk for Impaired Skin Integrity Knowledge Deficit rt. disease process & treatment Risk for Ineffective Management of Therapeutic Regime Risk for Ineffective Family CopingFinancial - *80% fed. Gov

Nsg. Diagnoses Continued*

Activity Intolerance rt. Effects of Anemia Impaired Comfort : puritis Chronic Sorrow rt. Chronic Illness Fatigue rt. Altered Body Chemistry Risk for Injury rt. bone changes, muscle weakness Decreased Cardiac Output rt. elevated K+ levels

Medical Goals of CRF

Preservation of Renal Function Delay of need for Dialysis or transplant Improvement of Body Chemistry Alleviation of Extrarenal effects Provide optimal quality of life

Dietary Restrictions*
Fluid Protein on dialysis high quality protein not limited on hemodialysis Potassium 60-70 mEg./day Sodium Phosphorus

Medications for CRF*

Diuretics Vitamins and Minerals Sodium bicarbonate Erythropoietin Calcium Preparations & Phosphorus Binders Antihypertensives

NIC Label: Nutrition Therapy

Nursing Diagnosis: Imbalanced Nutrition, less than body requirements

NOC Label: Nutritional Status

1= extremely compromised 3= moderately compromised

Outcomes Demonstrates improved nutritional status Consumes adequate nutrition Identifies nutritional requirements

NIC Interventions
Collaborate with dietician Teach family and client about prescribed diet Monitor and calculate food intake

NOC Label: Fluid Balance

1= extremely compromised to 5=not compromised Outcomes Remains free of edema, anasarca. Maintains clear lungs. Remains free of restlessness, anxiety, or confusion. Explains measures to prevent & treat excess fluid

NIC Label: Fluid Management

Nursing Diagnosis: Excess Fluid Volume

NIC Interventions
Monitor location of edema Monitor daily weight Monitor vitals: decreased. BP, tachycardia, tachypnea. Monitors gallop rhythm Teach patient & family about sx. of both excess and deficient fluid volume.

Goals for Dialysis

removal of end products of protein metabolism from blood- urea, creatinine maintenance of safe concentration of serum electrolytes correction of acidosis, replenishment of bicarbonate buffer system removal of excess fluid from blood

Hemodialysis vs. Peritoneal Finding the Best Fit*

Hemodialysis - a quick fix Not appropriate when hemodynamically unstable Not appropriate when trained personnel & vascular access not available Not appropriate for those unable to tolerate anticoagulation Peritoneal - slower, less aggressive Not appropriate for those with impaired respiratory excursion Not appropriate in sepsis, peritonitis, abdominal adhesions, abdominal adhesions or abdominal trauma

Key concepts of Dialysis*

Diffusion Filtration/Ultrafiltration Concentration gradient Osmosis

Vascular Access for Hemodialysis

Subclavian / internal jugular double lumen (Udall) AV fistula/AV graft

A Surgically Created Venous Fistula

Slide 75.7

An Arteriovenous Shunt of the Forearm

Slide 75.9

Examples of Multilumen caths

A Hemodialysis Circuit

Slide 75.5

Nursing Care of A-V Fistula*

Initially assess hemorrhage, infection, edema. elevate arm No B/P, venipunctures, I.V.s in access arm assess function of fistula - bruit & thrill assess distal pulse circulation Allens test no carrying heavy objects etc.

A Surgically Created Venous Fistula

Slide 75.7

Native Arteriovenous (AV) Fistula

the preferred type of vascular access for patients with end stage renal disease. AV fistulae result in significantly lower rates of complication (such as infection and clotting), longer patency, fewer hospitalizations, lower patient morbidity, and significantly lower costs compared to other accesses

Dialysis - Nursing Care*

Prior to Dialysis During Dialysis

KB Dialysis at 10AM
Meds: Atacand, Lasix, Regular insullin, Digoxin, Tums What do you give? Other Nsg. Duties? Nausea, hypertensive,

The Client Undergoing Hemodialysis

Weigh the client before and after dialysis. Know the client's dry weight. Decide whether any of the client's meds should be withheld until after dialysis. Be aware of events that occurred during the dialysis treatment. Measure blood pressure, pulse rate, respirations, and temperature..
Slide 75.17

Continued
Assess for symptoms of orthostatic hypotension. Assess the vascular access site. Observe for bleeding. Assess the client's level of consciousness and assess for headache, nausea, and vomiting.

Post- Dialysis Nsg. Management*

Disequilibrium syndrome Monitor for bleeding, hematoma & patency Neuro assessment, LOC

Peritoneal Dialysis*
Osmosis Diffusion Dialysate Concentrations Dwell time

Manual Peritoneal Dialysis Via Implanted Abdominal Catheter (Tenckhoff Catheter)

Slide 75.13

installations and dwell periods dialysate outflow times

Nursing Management of Peritoneal Dialysis*

Peritoneal Dialysis - types

Continuous Ambulatory Peritoneal Dialysis (CAPD) Automated Peritoneal Dialysis (ADP) can be run at different time intervals Two forms of ADP 1. (CCPD) continuous cyclic with 3 cycles at noc and one 8 hr. in morning 2.(IPD)intermittent 10-14 hrs/ 3-4 x wk., NPD nightly peritoneal dialysis 8-12 hrs at noc.

The used Dialysis Bags are 'Clinical Waste'. The Renal Unit will contact the local authority for you and arrange for free yellow coloured clinical waste bags to be delivered to your home (usually four a week. You will need only two bags but they need to be double wrapped). They will also arrange for a free weekly collection of the full bags. Flatten your cardboard boxes (see diagram on the box) and put out for your regular rubbish collection.
Please click on the links below for further CAPD info. Weight & Fluid Balance | Clean Procedures : Infection | General Info

Complications of Peritoneal Dialysis*

Peritonitis- meticulous aseptic technique. Check fever, rebound tenderness, nausea, WBCs, malaise Hyperglycemic & hyperosmolar states Esp. with high glucose dialysate Cath. Displacement Abd. Discomfort Lack of compliance when self dialysing

Assess laboratory data, including BUN & Creatinine Creatinine clearance CBC Electrolyte Assess psychosocial status, including Presence of anxiety Presence of maladaptive behavior
Slide 75.20

Nsg. Management of ESRD at Home

Monitoring Community Resources

Kidney Transplant*
Living Related Living Unrelated Cadaver United Network for Organ Sharing, Richmond Va. National kidney transplant waiting list - 38,760 First successful transplant -1954 - Dr. Jos. Murray, Brigham & Womens Hospital Boston MA.

Kidney Donor
Selection Process

Hand-assisted Laproscopic Donor Nephrectomy

www.or-live.com/meritcare/1145/ www.matchingdonors.com 3-5 incisions in donor abdomen Full recovery in up to 6 weeks

Placement of a Transplanted Kidney to the Right Iliac Fossa

Slide 75.16

Nursing Responsibilities
Post Transplant

Renal Transplant Complications*

Graft rejection hyperacute, acute, or chronic Other complications: infection, disease recurrence, complications of drug therapy, ulcers, HTN, steroid-induced diabetes etc.

Hyperacute Rejection*

Hyperacute Rejection
Onset Within 48 hr after surgery Clinical Manifestations Increased temperature Increased blood pressure Pain at transplant site Treatment Immediate removal of the transplanted kidney
BUN = blood urea nitrogen.

Slide 75.21

Acute Rejection*

Acute Rejection
Onset 1 wk to 2 yr postoperatively (most common in first 2 wk) Clinical Manifestations
Oliguria or anuria Temperature over 37.8 C (100 F) Increased blood pressure Enlarged, tender kidney Lethargy Elevated serum creatinine, Blood Urea Nitrogen, potassium levels Fluid retention

Treatment

Increased doses of immunosuppressive drugs

BUN = blood urea nitrogen. .

Slide 75.22

Chronic Rejection*

Chronic Rejection
Onset Occurs gradually during a period of months to years Clinical Manifestations
Gradual increase in Blood Urea Nitrogen and serum creatinine levels Fluid retention Changes in serum electrolyte level Fatigue Treatment Conservative management until dialysis is required
Slide 75.23

Immunosuppressive therapy after Renal Transplant*

FK-506 - 100 X more Corticosteroids potent than Prednisone or cyclosporin methylprednisone (Solu-medrol) OKT-3 - monoclonal antibody Azathioprine (Imuran, CellCept, Antilymphocyte Cyclosporine - used globulin - Atgam with steroids (ALG) (Sandimmune or Neoral)

Nursing Problems rt. Immunosuppression

increased risk of infection bone marrow suppression incidence of malignancy- lymphoma c/o with steroids - gastritis & peptic ulcer disease, bone weakness, GI bleeding, steroid induced DM, F&E imbalance

Common Types and Locations of Renal Trauma

Minor Trauma

Slide 74.7

Common Types and Locations of Renal Trauma

Pedicle Injury

Slide 74.8

Common Types and Locations of Renal Trauma

Major Trauma

Slide 74.9

Common Types and Locations of Renal Trauma

Slide 74.11

NURSING MANAGEMENT

The Patient with Bladder Cancer*

Primary prevention: Stop Smoking doubles the risk Secondary prevention: Hematuria? Men 3X more likely Chemicals in the workplace dye, leather, rubber Whites more likely Age late 60s 53,000 new cases in 2000 94% survival rate

Symptoms
Blood in the urine (slightly rusty to deep red in colour). Pain during urination. Frequent urination, or feeling the need to urinate without results.

Bladder Cancer

Bladder Tumors

Treatment Modalities*
Chemotherapy Radiation Surgery: Partial Cystectomy Total Cystectomy
TURP

Treatment Continued

Total Cystectomy with Urinary Diversion*

Ileal Conduit Continent Internal Ileal Reservoir (Kock Pouch) Cutaneous Ureterostomy Vesicostomy

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.9

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.10

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.11

Urinary Diversion Procedures Used in the Treatment of Bladder Cancer

Slide 73.12

Hollister*

Sure-Fit Natura

Face Plate Cut to Fit Skin Barrier*

Karaya 5 Lo-Profile Urostomy Pouch

Nursing Management of Patients Requiring Urinary Diversion*

Psychological Needs Immediate Post-op

Postoperative Nursing Care of Patient with Urinary Diversion*

Immediate Post-op: Hypovolemia, hematuria, stoma checks 48 hrs. or more: peritonitis Stoma care

Case Study
Patient with Ileal Conduit

Nsg. Dx & Outcomes rt. Pt with Ileal Conduit*

Knowledge Deficit rt Stoma Care Social Isolation rt Fear of Accidental leakage Risk for Imapired Skin Integrity Disturbed Body Image Demonstrates how to perform pouch change & ostomy care 1=no knowledge 5=
extensive knowledge

Participates in activities to level of ability & desire 1= no social

involvement;5= extensive

Regains integrity of skin surface.

Client Education of the Patient with a Urinary Diversion

Developing a Teaching Care Plan

Cancer of the Prostate*

Function of Prostate GlandPrevention of Prostate Cancer and Detection

Anatomy

The Prostate Gland with Cancer and Benign Prostatic Hyperplasia

Slide 79.12

Diagnostic Tests and Physical Exam*

PSA assay Rectal exam Transrectal /Transperineal and Percutaneous needle aspiration and Biopsy Other diagnostic tests

Treatment Modalities and Management of Prostate Cancer*

Hormone therapy Chemotherapy Radiation Surgery

Pharmacology - Hormone therapy*

Androgen supressing agents ex. finasteride (Proscar) flutamide (Eulexin) - a new androgen blocker leuprolide (Lupron) a gonadotropin analogue

Leuprolide (Lupron) s.c. - Side Effects

Dizziness, HA N&V, Anorexia, Constipation Peripheral edema, Cardiac Arrhythmias Hot flashes, sweats

Chemotherapy or Radiation
Cytoxan Adriamycin

Types Prostate Surgery*

Laser Cryosurgery Robotic Prostatectomy www.davinciprostatectomy.com

Radical Open Prostatectomy*

Suprapubic approach Retropubic approach Perineal approach

Suprapubic, or Transvesical, Prostatectomy

Slide 79.6

Retropubic, or Retrovesical, Prostatectomy

Slide 79.7

Three Way Foley Catheter

Perineal Prostatectomy

Slide 79.8

Nursing Care Following Prostate Surgery*

Hematuria Bladder spasms Hemorrhage Retropubic - care of the low ABD incision & Suprapubic catheter Discharge teaching

Effects of Surgery*
Client is STERILE Erective Dysfunction (if pudental nerve fx. Spared 3-6 mos of ED ( impotence) Urinary Incontinence if internal & external urinary sphincters involved.

Care Immediately after Radical Prostatectomy

Encourage the client to use patient-controlled analgesia (PCA) as needed. The PCA device may be used through the second postoperative day. Keep the client on bed rest on the day of surgery. Help the client to get out of bed and ambulate for a short distance by the first postoperative day. Keep the client on NPO status as ordered, usually until the first or second postoperative day.

Slide 79.11

Care after Radical Prostatectomy Continued

Maintain the sequential compression device until the client begins to ambulate. Apply antiembolic stockings until discharge. Monitor the client for deep vein thrombosis and pulmonary embolus. Keep an accurate record of intake and output, including Jackson-Pratt or other drainage device drainage.

Slide 79.11

Teaching Following Radical Prostatectomy*

You are developing a handout for patients following radical open prostatectomy . What are the essentials?

Pt. Teaching following Radical Prostatectomy

Keep the urinary meatus clean using soap and water. Avoid rectal procedures or treatments. Teach the client how to care for the urinary catheter because he will be discharged with the catheter in place. Teach the client how to use a leg bag. Emphasize the importance of not straining during bowel movement. Advice the client to avoid suppositories or enemas. Remind the client about the importance of follow-up appointments with the physician to monitor progress.
Slide 79.11

Leg Bag

Discharge Teaching following Radical Prostatectomy

Remind client about importance of followup appointments with M.D. Exercises for Urinary Incontinence :tighten perineal muscles, biofeedback Function ED alternatives:prostheses, vaccum devices, viagra.

Nsg. Diagnoses Associated with Radical Prostatectomy*

Knowledge Deficit rt Self Care & Home Maintenance Acute Pain rt. Bladder Spasm Risk for Urinary Incontinence Risk for Sexual Dysfunction NOC Outcomes: expresses comfort with sexual expression 1-= never demonstrated; 5 = consistently
demonstrated

Potential Complications
Sexual dysfunction with radical perineal prostatectomy Urinary incontinence with radical prostatectomy

The End