Chapter 45:   Upper Urin syst=kidneys,ureters Lower=bladder,urethra Kidney Functions: 1>Regulate the volume and composition of extracellular fluid 2>excrete waste products from body 3>control BP, produce erythropoietin, activate vitD, regulate acid, base balance. Located T12 to L3. Nephron is functional unit of kidney.  GLomerulus:Selective filtration. Proximal tubule:reabsorption 0% electrolytes and water reabsorption all glucose and amino acids, reabsorption HCO3, secretion of H+ & creatinine. Loop of Henle:reabsorption NA &Cl- in ascending limb; reabsorption water in descending loop; concentration of filtrate. Distal tubule:secretion of K+, H+, ammonia;reabsorption of water; reabsorption of HCO3-, regulation of Ca2+ & PO4 2- by parathyroid hormone, regulation of Na+ and K+ by aldosterone. Collecting Duct:Reabsorption of water (ADH required)  Uretropelvic Junction:narrow area at point each ureter joins the renal pelvis. Bladder: serve as reservoir for urine and eleminate waste products from body. Typically urinate 5-6times day 200-250ML in bladder causes urge to urinate. 400-600=uncomfy 600-1000=capacity Urethra: serve as conduit for urine from the bladder neck to outside the body during voiding. Female- 1-2in male-8-10in Urethrovesical Unit: bladder urethra and pelvic floor muscles. Control=continence Gerontologic consider: 20-40% loss size &weight btw ages 30-90. seventh decade = 30-50% glomeruli lose function. Kidney: <amnt renal tissue= less palpable. <number of nephrons &renal blood vessels. thick basement mem= ,creatinine clearance >BUN >serum creatinine. <loop of hence function= alterations in drug excretion;nocturne;loss normal diurnal pattern, less concentrated urine. Bladder: <elasticity&muscletone= palpable bladder after urination. weakening sphincter=stress incontinence. ,bladder capacity=frequency, nocturne, urgency, overflow. estrogen deficiency=stress/overactive bladder, dysuria. >prevalence unstable bladder contractions=overactive bladd. prostatic enlarge= hesitancy, frequency, urgency, nocturne, straining, retention, dribble. General urinary cyst manif: fatigue,headache,blur vision,>BP,anorexia,naus&vom,chills,itch,excess thirst,change weight,cognitive changes. Norm assess urinary: No cotovertebral angle tenderness, nonpalpable kidneys and bladder, no palpable masses. Anuria:no urine 24hrs <100ml, Dysuria: pain Enuresis: involun nocturnal urinate Hematuria: blood Oliguria: 100-400ml Pneumaturia: gas in urine polyuria: large amnts. Diagnostics: Creatinie clearance=collect 24hr urine specimen discard first one. approximates GFR (urine creatinine)(urine volume)/ Serum creatinine BUN= 6-20 Creatinine= 0.6-1.3 BUN/creatinine ratio= 12:1-20:1 Uric Acid=F; 2.3-6.6 M; 4.4-7.6 Sodium= 135-145 Potassium= 3.5-5 Calcium= 8.6-10.2 Phosphorus= 2.4-4.4 Bicarbonate= 22-26 Radiologic Procedures KUB: perform bowel prep. IVP: Eve b4 give cathartic or enema. B4 proceed assess for iodine sensitivity to avoid anaphylactic reaction. Inform procedure and about serial x-rays advise that warmth flush face and a salty taste during inject contrast may occur. After force fluids. Antegrade pyelogram: Explain proceed and prepare for IVP watch for hematuria, infection, hematoma. Retrograde pyelogram: Prepare like IVP. inform pain may occur from distention of pelvis &discomfort from cystoscope. Anethesia may be given. Angiogram: Prior same as IVP After place pressure dressing over femoral artery. Peripheral pulses involved leg every 30-60min observe 4 thrombus, embolus, inflammation, hematoma Urinalysis: Color; dark.smoky=hematuria, yellow brown/olive green= excess bilirubin, orage-red/orange brown= pyridium, cloudy=infection colorless=excess fluid intake,renal disease, diabetes insip. Odor=UTI if urine stands smells ammonia like. Glucose present=diabetes. Ketones present= altered carb &fat metabolism in diabetes and starvation Bilirubin present= liver disorder CHAPTER 46 UTI= second most common bacterial disease in women. Microorganisms to cause UTI= E.coli, enterococcus, klebsiella, enterobacter, proteus, pseudomonas, staphylococcus, serrate, candida albicanst. pyelonephritis= inflammation of renal parenchyma and collecting system. Cystits= inflammation bladder wall Urethritis= inflammation urethra. Urospepsis= UTI that has spread into the systemic circulation=life threatening condition. Uncomplicated= occur in ormolu urinary tract and only involve bladder Complicated= coexisting with obstructions, stones, or catheters;existing diabetes or neurologic diseases;pregnancy induced; or an infection that is recurrent Predisposing Facotrs to UTI= Factors increasing urinary stasis (intrinsic obstruction, extrinsic obstruct., renal impair) Foreign bodies (UT calculi, catheters, UT instrumentation), Anatomic factors(congenital defects, fistula, shorter female urethra, obesity), Compromising immune response(aging, human immunodeficiency virus, Diabetes), Functional disorders(constipation, VOiding dysfunction) Others(pregnancy, hypoesrogenic state, multiple sex partners, use of spermicidal agents, poor hygiene) LUTS= Hesitancy, intermittency, postpaid dribbling, urinary retention, dysuria, pain, frequency, urgency, incontinence, nocturne, nocturnal enuresis. Diagnostics: History&Physical, Urinalysis(clean catch midstream), Urine for culture and sensitivity, Imaging(IVP, cystoscopy, ultrasound) Colaborative therapy: Uncomplicated= Antibiotics, patient teaching, adequate fluid intake Complicated= repeat urinalysis, urine culture, imaging, antibiotics, adequate fluid intake, patient teaching. Bladder Irritants= caffeine, alcohol, citrus juice, chocolate, spicy foods. UTI PATIENT TEACHING: 1.importance taking all antibiotics 2.appropriate hygiene 3.importance empty bladder b4 and after sex 4.urinate regularly(every 3-4hrs) 5.maintain adequate fluid intake 6.avaid bubble baths and harsh soaps 7.report symptoms of recurrent UTI 8. Suggest possible use of cranberry juice. Acute pyelonephritis= usually begins colonization and infection of lower UT via the ascending urethral route.  Clinical manifestations= mild fatigue to sudden onset chills fever vomiting malaise flank pain and LUTS, CVA pain. Urinalysis FIndings: pyuria, bacteriuria, and hematuria. WBC casts may be found indicating involvement of renal parenchyma. CBC shows leukocytosis and increase in immature neutrophils. Urosepsis is characterized by bacteriuria an bacteremia. IF BACTERIMIA is a possibility close observation and vital sign monitoring are essential. NUSING INTERVENTIONS= 1.need to continue medications as prescribed 2.need for follow-upurine culture to ensure proper management 3.identification of risk for recurrence or relapse in addition to antibiotic therapy. Chronic Pyelonephritis= kidneys have become small, atrophic, and shrunken. Have lost function owing to scarring or fibrosis. Radiologic and histologic testing used to confirm diagnosis. Imaging reveals a small contracted kidney with thinned parenchyma. Urethral Diverticula= result of obstruction and subsequent rupture of the peripheral glands into the uretral lumen with epithelialization over the opening of the resulting periurethral cavity. INTERSTITIAL CYSTITIS=painful bladder disease= chronic painful inflammatory disease of the bladder characterized by frequency and pain. subrapubic pain related to bladder filling. Criteria for for diagnosis= INCLUSION (pain during bladder filling, bothersome urinary urgency and frequency, small bladder capacity, cystoscopic evidence of ulcerations or glomerulations) EXCLUSION (bladder capacity >350, overactive bladder contractions, daytime voiding <8times a day, active genital herpes, hist of chemotherapy, tubercular cystitis, history pelvic radiation, bladder tumor) OTC supplement prelief(calcium phosphorus) can help provide relief by alkalinizing the urine Renal tuberculosis= rarely a primary lesion. Usually secondary to TB of the lung. Symptoms of UTI are the first sign in majority of those with renal TB. GLOMERULONEPHRITIS=inflammation of glomeruli, affects both kidneys. CLASSIFICATIONS 1.extent of damage 2.initial cause of disorder 3.extent of changes. Clinical Manifestations: hematuria, RBCs, WBCs, casts in urine, proteinuria and elevated BUN and creatinine. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS= most common in child and young adults. develops 5-21 days after an infection of tonsils, pharynx, or skin. MANIFESTATIONS=edema, hypertension, oliguria, hematuria with a smoky or rust appearance, and proteinuria. COLLABORATIVE CARE= H&P, urinalysis, CBC,BUN, Renal biopsy, Rest, sodium and fluid restrictions, diuretics, antihypertensive, adjustment of dietary protein intake to level of proteinuria and uremia. Good pasture syndrome= autoimmune disease characterized by the presence of circulating antibodies against glomerular and alveolar basement membrane and is rare. NEPHROTIC SYNDROME=results when the glomerulus is excessively permeable to plasme protein causing proteinuria that leads to low plasma albumin and tissue edema. CAUSES= membranous proliferative glom, primary neprotic syndrome, focal glom, inherited nephrotic disease, lupus, diabetes, amyloidosis, infections, hodgkins, tumors, leukemias, allergens, drugs. TREATMENT= symptom management. rellieve edema and cure or control primary disease. NEPHROLITHIASIS= Kidney stone disease Risk factors= Metabolic(increased levels of calcium, oxalic acid, uric acid, or citric acid in urine) Climate(warm) DIet(large intake proteins, excess tea or juices, large calcium and oxalate intake) Genetics, Sedentary Lifestyle. Calculus= Stone 1.calcium phosphate, 2.calcium oxalate, 3.uric acid, 4.cystine, 5.struvite CALCIUM OXALATE=small often trapped in ureter men>women-Increase hydration reduce dietary oxalate, give thiazide diuretics, reduce sodium intake. CALCIUM PHOSPHATE= mixed stones-treat underlying causes of other stones. STRUVITE= women>men always with UTIs large staghorn type-administer antimicrobial agents, use surgical intervention to remove stones,acidify urine. URIC ACID= predominant in men- reduce urine concentration of uric acid with potassium citrate. reduce purines. CYSTINE= genetic autosomal recessive defect-increase hydration. PURINE FOODS= sardines, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads CALCIUM FOODS= milk, cheese, ice cream, yogurt, beans, lentils, fish, dried fruits, nuts OXALATE FOODS= spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery parsley, beans. cocoa, coffee, tea Indications for surgical removal= 1. too large for passage 2.associated with bacteriuria or infection 3.causing impaired renal function 4.causing persistent pain, nausea, or ileum 5.inability of patient to be treated medically 6. pt with one kidney. NURSING ASSESSMENT UT CALCULI= guarding, back pain, fever, dehydration. Warm flushed skin or pallor with cool moist skin (mild shock). Abdominal distention, absence of bowel sounds. Oliguria, hematuria, tenderness on palpations of renal areas, passage of stone. Increased BUN and creatinine. RENAL TRAUMA INTERVENTIONS= assess cardiovascular status, monitor for shock, ensure increased fluid intake, monitor I&O, provide comfort measures, observe for hematuria, determine precense of myoglobinuria, monitor potentially nephrotic antibiotics. RENAL ARTERY STENOSIS= occlusion of one or both renal branches and their major branches=hypertension develops abruptly. KIDNEY CANCER= no early symptoms so many go undiagnosed until it has metastasized stage I=limited to kidney stage II= spreading to perirenal fat but confined within fascia stage III= tumor invades renal vein or vena cave, or regional lymph node involvement or both. stage IV= presence of setastases. STRESS INCONTINENCE= sudden increase in intraabdominal pressure- pelvic floor muscle exercises, weight loss, smoking cessation, estrogen products, bladder neck support. URGE= involuntary urination is preceded with urgency- treat underlying causes. bladder retraining, anticholinergics, containment devices, absorbent products. OVERFLOW= urinary catheterization to decompress bladder, support prolapse, intermittent cat, surgery REFLEX= bladder decompression, intermittent self-cath, surgical sphincterotomy. INTERVENTION FOR URINARY INCONTINENCE= lifestyle mod. scheduled voiding regimens, pelvic floor muscle rehab, anti-incontinent devices, containment devices. URETHRAL CHATHETERIZATION= 1. pt should receive appropriate instruction regarding care. 2.sterile closed drainage system should be used 3.perineal care 1-2 times a day with soap and water 4.all catheters should be anchored using some type of securement device. 5.sterile technique must be used when collecting system is open. 6. small volumes of urine for culture can be aspirated from the sampling port with sterile syringe. 7.when pt cathode for less than 2 weeks routine cat change not necessary 8. with long term cat use a leg bag may be used 9. remove cat at earliest moment possible. DELEGATION FOR CATHETERS= LPN=insert intermittent or indwelling cat, irrigate cat in place. NAP=provide perineal care, anchor cat in place. DELEGATION CARE FOR INCONTINENT= LPN=use bladder scanner, cat patien and measure post residual volume, administer med. NAP= assist pt to commode, clean pt and provide skin care, Notify RN about new-onset incontinence URINARY STOMA= symmetric, no skin breakdown, protrudes about 1.5sm, mucosa is a healthy red. 

CHAPTER 47=   ACUTE KIDNEY INJURY: Onset: Sudden, Common DIagnostics: Acute tubular necrosis, acute reduction in urine output, elevated serum creatinine, Reversibility: Potentially Mortality: High 60% Primary cause of death: Infection  CHRONIC KIDNEY DISEASE: Onset:Gradual Common diagnosticsDiabetic nephropathy, GFR <60 for >3mo, kidney damage >3mo Reversibility: Progressive and reversible Mortality: 19%-24%(pts on dialysis) Primary cause of death: Cardiovascular disease  AKI: Causes; Prerenal=causes external to kidneys. reduce systemic circulation causing reduction in renal blood flow and lead to decreased glomerular perfusion and filtration to kidneys.(Hypovolemia,decreased cardiac output, decreased peripheral resistance,decreased renovascular blood flow) Intrarenal= conditions that cause direct damage to the kidney tissue resulting in impaired nephron damage (ATN is most common) (Nephrotic injury,interstitial nephritis) Postrenal= causes involve mechanical obstruction in the outflow of urine. (enlarged prostate, bladder cancer, calculi, spinal cord disease, strictures, trauma) STAGING FOR AKI: Risk;creatinine increase X1.5 or GFR increase 25% Urine output <0.5ml/hr Injury;creatinie increased X2 or GFR 50% urine <0.5ml/12hrs Failure;creatinine increasedX3 or GFR 75% OR creatinine>4 urine , 0.3ml/24hrs (oliguria) or anuria for 12hrs Loss;persistent acute kidney failure: complete loss of kid function >4wk End stage;complete loss of kid function >3mo MANIFESTATIONS AKI: Urinary changes; oliguria, Fluid volume depletion (hypovolemia), Metabolic acidosis, Sodium balance(low) Potassium excess, hematologic disorders, waste product accumulation, neurologic disorders Diuretic phase: gradual increase in daily urine output of 1-3L day. Caused by osmotic diuresis from high urea concentration in the glomerular filtrate inability to concentrate urine. Kidneys have recovered ability to excrete waste but not to concentrate urine. Recovery Phase: Begins when the GFR increases allowing the BUN and creatinine to plateau then decrease. kidney function may take up to 12mo to stabilize. COLABORATIVE CARE: Treat precipitating causes, Fluid restrict (600ml plus previos 24-hr loss), Nutritional therapy (adequate protein intake, potassium restrict, phosphate restrict, sodium restrict) Lower potassium if high, calcium supplements, enteral nutrition, parenteral nutrition, initiation of dialysis, continual renal replacement therapy.) THERAPIES FOR ELEVATED POTASSIUM LEVELS: Regular insulin IV (potassium moves into cell walls when insulin given, IV glucose is given concurrently to prevent hypoglycemia) Sodium bicarbonate:(correct acidosis and cause a shift of potassium into cells) Calcium carbonate IV (Used in advanced cardiac toxicity. Calcium raises threshold for excitation) Dialysis, Kayexalate, Dietary restrictions ASSESSMENT: important to monitor vital signs and I&O. urine output, daily weight. CKD STAGES= stage1 kidney damage with norm or high GFR GFR=>90 diagnosis and treatmentCVD risk reduction, slow progression Stage 2 kidney damage with mild decrease GFR GFR=60-89 Estimate progression stage3 moderate decrease GFR GFR=30-59 evaluate and treat complications stage 4 severe decrease GFR GFR=15-29 prepare for kidney replacement therapy. Stage5 kidney failure GFR <15 Kidney replacement  MANIFESTATIONS CKD: Psychologic=anxiety,depression. Cardio=hypertension,heart failure, coronary artery disease, pericarditis, peripheral artery disease. Gastro= nausea, vomiting, anorexia, bleeding, gastritis. Endocrine= hyperparathyroidism, thyroid abnormalities, amenorrhea, erectile dysfunction. Metabolic= carb intolerance, hyperlipidemia. Hematologic= anemia, bleeding, infection. Neurologic= fatigue, headache, sleep disturbances, encephalopathy. Ocular=Hypertensive retinopathy Pulmonary= edema, pleuritis, pneumonia. integumentary=pruritis, ecchymosis, dry skin. Musculoskeletal= vascular&soft tissue calcifications, osteomalacia, osteitis fibrous. COLABORATIVE THERAPY: correct fluid overload, nutrition therapy, erythropoeitin therapy, calcium supplementation, antihypertensives, ACE inhibitors, treat hyperlipidemia, lower potassium, dialysis/kidney transplant. RISK FACTORS= diabetes, hypertension, age >60, card disease, family history, exposure nephrotic drugs, ethnic minority. NUTRITION THERAPY: Protein restrict. water restrict. sodium potassium restrict. phosphate restrict. HIGH POTASSIUM FOODS= apricot,avocado,banana,melon, raisins, beans, broccoli, carrots, potatoes, milk, PB, salt substitutes, yogurt. CKD TEACHING= 1.necessary diet 2.difficulties in modifying diet and fluid intake 3.signs&symptoms electrolyte imbalance 4.alternative ways to reduce thirst 5.Medication education 6.importance of weight gain,increased BP, SOB, edema, increased fatigue, confusion 7.need for support and encouragement. DIALYSIS= movement of fluid and molecules across a semi permeable membrane. PERITONEAL DIALYSIS= Use of catheter in abdominal cavity. less complicated, fewer dietary restrictions, him dialysis, less card stress, preferred for diabetic. HEMODIALYSIS= rapid fluid removal, less protein loss, use of vascular site.  COMPLICATIONS= hypotension, muscle cramps, loss of blood, hepatitis COMPONENTS HD= blood removed via needle inserted into fistula or catheter lumen. propelled to dialyzer by a blood pump. Heparin is infused either as a bolus predialysis or through a heparin pump continuously to prevent clotting. Dialysate is pumped in and flows the opposite direction of the blood. The dialyzed blood is returned through pt through second needle or catheter lumen. old dialysate are drained and discarded. CRRT DIFFER FROM HD= 1. continuous rather than intermittent. 2.solute removal can occur by convection 3.it causes less hemodynamic instability. 4.does not require constant monitoring by a specialized HD nurse. 5.Does not require complicated HD equipment. COMPONENTS CONTINUOUS VENOVENOUS THERAPIES= Blood pump is required to pump blood through the circuit. replacement ports are used for instilling replacement fluids and can be given prefilter or postfilter. dialysate port is used for infusing dialysis solutions.  Ultrafiltrates drained via the ultrafiltration drain port. POSTOP CARE LIVE DONOR= closely monitor renal function to assess for impairment, moonier hematocrit to assess fro bleeding. Discharged 4 or 5 days and can return to work in 4-6 weeks. KIDNEY RECIPIENT POSTOP CARE= maintain fluid and electrolyte balance is first priority.