Renal Concepts Overview

Multiple Concepts to explore

• Fluid Volume Excess
• Altered Electrolyte Balance
• Immobility/Integumentary
• Look for Infection
• Client needs Coping Skills
• Review Nutrition
• Evaluate Oxygenation
• Specific pathophysiology issues
• Electrolyte Imbalance- Decrease in GFR leads to electrolyte imbalance
• Cardiac dysrhythmias
• Edema from Na and fluid retention
• Effect parathyroid hormone (PTH) and calcitonin from thyroid
• Calcitonin moves Ca into bone; PTH shifts Ca from bone to
ECF
• Increase P = decrease Ca + PO4 = bone demineralization (renal
osteodystrophy
• Anemia and Bleeding- impaired O2 transport due to decreased
erythropoietin production
• Check skin for dryness, flakiness, ecchymosis, yellow-gray due to
toxins and/or uremic frost: pruritus
• Tips – Increase K, Phos, Mg, BUN, Creatinine, Na high but dilutional
Decreased Calcium, Hemoglogin/Hematocrit
Phosphorus and Calcium are inversely related: when Phosphorus is high, calcium is low.

Renal and Urinary Tract Assessment

• Renal system is composed of two kidneys an the urinary system is composed of
two ureters, bladder, and the urethra
– Work together to provide for homeostasis in the body
• Kidney functions
– Secretion of waste
– Regulation of fluid and electrolytes
– Regulation of acid-base balance
– Regulation of blood pressure
– Secretion of erythropoietin for RBC production
– Activation of vitamin D
• Urinary Tract
– Storage and passage of urine
– Promoting continence
– Facilitating voiding

• The function of the kidney is to filter and absorb majority.

• 1% is eliminated and 99% is absorbed.
 • Kidneys located retroperitoneal space either side of the spinal column
– Left kidney is higher due to position of liver**
– Outer most portion is the is renal capsule
– The hilum is location where vessels and nerves enter and leave
– The ureters also leave via the hilum
• A nephron the functional unit of the kidney (Fig. 61.3)
– 800,000 to 1.2 nephrons per kidney
– Filters blood to remove waste and produce urine
– Composed of glomerulus (actually filters blood which is GFR normal
125mL/min achieving 180 L of filtrate per day) of which 1 to 3 liters of filtrate
is actually excreted as urine. Fig 61.7
– Bowman’s capsule ( proximal & distal tubules with Loop of Henle)
responsible for reabsorbing different substance
• Blood supply 25% cardiac output @ 1200 ml/hr off the abdominal aorta and venous
return to the vena cava
– Powerful compensatory mechanism above BP of 70 mm Hg
– Substances are generally reabsorbed; agents > than renal threshold escape
into urine, i.e. glucose, etc., into the urine (Fig, 61.8)

Important concepts
• Processes of importance- Glomerular filtration, Tubular reabsorption, Tubular
secretion, Urine Concentration
• To avoid dehydration up to 99% of filtrate is reabsorbed and returned to blood
• Different parts of tubule are responsible for secretion and reabsorption
• Substances such as potassium ions (K) & hydrogen ions (H). Both are secreted back
into filtrate necessary to maintain stable electrolyte and blood pH level
• Kidneys primary organ maintaining water balance. Water taken in = water lost (Fig
61.9)
• Osmolality - concentration of solutes contained in blood 275-295mOsm/kg
– Review figures 61.10 thru 61.12
– Table 8.5 Pg 121
– Osmolality vs Osmolarity are unit of measurement, Kg of solvent vs osmoles
of solute in a liter of solution

Urinary Structure Points

• Ureter is a small hollow tubes from the renal pelvis that join the the bladder on the
posterior side at the ureterovesical junction
– Site of joining to bladder are frequently associated with obstruction
• Bladder stores urine until excreted from the body
• It is located posterior to the symphysis in the pubis, anterior to the rectum and in
women anterior to the vaginal wall and inferior to the uterus
• Total capacity varies from 600mL to 1000 mL of urine
 • Bladder composed of 3 muscles…middle is the detrusor which distends and
contracts as bladder fills and empties.
• Another layer, the urothelium which forms rugue when bladder is empty, resist the
absorption of urine, and ensures urine stays in the urinary tract. It also secrete a
substance which resist bacterial colonization, the trigone is a triangular region point
at entrance of ureters and urethra common location of bladder infection
• Bladder allows for continence and facilitates voiding
• Continence is ability to voluntarily control emptying
• Micturation, the act of releasing urine, is a learned response corrinated by the brain
and spinal nerves that innervate the bladder.
• Impulses to sacral cord (S2&S4)urge to void and brain send via (T11&L2) to relax
and void****read page 1423 and see Fg 61.13

• Urethra in male is 8-10 in, extends from bladder thru the prostate , and the length of
the penis.
• Urethra in female is only 1 -2 inches which accounts for bacteria to more easily
invade the urinary tract.
• Control of the internal urethral sphincter is involuntary while control of the external
sphincter is voluntary
• Assessment: review all. Look at medication Use
• Average person voids 5 to 6 times a day and does not regularly need to void
overnight
• Renal and Urinary Assessment Abnormalities, Table 61.1 Pg 1426
• Locate kidneys along the costovertebral angle (CVA) as a landmark which is formed
by lower border of the 12 rib and the spine
• Creatinine end product of protein and muscle breakdown; most reliable indicator of
kidney function. Increase does not occur until 50% of kidney function has been lost.
Normal value 0.5 to 1.2 mg/dL (Male has higher creatinine)
• BUN by-product of protein metabolism that occurs in liver. Normal range is 8-21
mg/dL, increases in renal disease, liver disease, dehydration, infection, GI bleeding,
steroid use and trauma. Dehydration causes higher BUN level.
• BUN/Creatinine ratio used to assess if > BUN is renal or non-renal. Normal ratio is
10:1 to 20:1. See discussion pg 1428
• 1.005 – 1.035 is the normal specific gravity.
• Creatinine, BUN, Specific gravity, Glomerular - important levels**

Table 62.5 Laboratory Values Related to Renal Failure

Page : 1542
Whole Page is From Book

Box 62.1 Teaching Measures to Reduce the Incidence of Urinary Tract Infections

Teaching the patient and family measures to reduce the incidence of urinary tract
infections should include the following:

The importance of taking antibiotics as prescribed. Tell the patient and family that
symptoms may improve in 1 to 2 days; however, the prescribed antibiotic medication
regimen should be completed.
Proper hygiene, including instruction on the careful cleansing of the perineal area with
soap and water with bathing and after defecating, moving back the folds of the labia, and
cleaning the area from front to back with each cleaning, especially after urination.
The importance of emptying the bladder before and after sexual activity in order to avoid
the risk of pathogens entering the urinary tract.
Urinating regularly throughout the day, suggesting a micturition frequency of every 3 to 4
hours.
The importance of adequate fluid intake. A full eight glasses of water per day is
recommended.
Avoiding the use of vaginal douches, harsh soaps, bubble baths, powders, and sprays in
the perineal area.
The signs and symptoms of urinary tract infection, such as frequency, urgency, hesitancy,
change in urine color (e.g., cloudy appearance), pain on urination, and fever.
The use of unsweetened cranberry juice for the prevention of urinary tract infection.

Nursing considerations for patients receiving IV contrast for radiographical studies:

• Confirm the presence of signed informed consent.

• Assess patient for a history of allergies to contrast, iodine, and shellfish. Patients with a
history of these allergies may be premedicated with steroids.
• Confirm the presence of emergency medications and equipment at the bedside.
• Review baseline serum creatinine as evidence of renal function.
• Review patient history for the presence of renal dysfunction and comorbidities that would
increase the risk of acute kidney injury such as hypertension or diabetes.
• Educate the patient regarding the flushing sensation and salty taste they may notice
during contrast administration.
• Ensure the patency of the IV.
• Assess the patient for signs of a delayed reaction to contrast (e.g., rash, dyspnea,
tachycardia).
• Ensure that the patient increases fluid intake following the study.
• If warranted, monitor subsequent serum creatinine laboratory values.
REVIEW PAGE 1512-1513 (Glucose)
REVIEW Page 1538-1539
Know the assessment of patients with urinary renal function** Chapter 61

• Review all test, look for specific indicators for change

• Normal Urinalysis results and abnormal findings (Table 61.2 Pg 1430)
• Look for commonalities and or required activities; lab test, wt, medications, etc.
Necessary pt education pre and post test
– Allergies
– Pre and post test medication, i.e., no blood thinners prior to test
– Consent signed
– Necessary blood test before exam started
– Fluid status before test, i.e., NPO, etc.
– Hydration after exam, fluids to flush dyes depends on pts fluid status
– Site preparation before and after test, i.e. pressure on site, position of
extremity
• Age-Related Changes Pg 1436)
GFR decreases with age 65 to ½ or 65mL/min

Polycystic Kidney Disease (PKD) – Genetic disorder, kidneys full of cysts that can
develop over time. Page 1522 in book
• Progressive disorder causing excessive growth of fluid filled cysts
• Two (2) forms PKD, childhood and adult
• Adult form appears in 3d and 4th decade of life
• Prevalence same for men and women, involves both kidneys
• Genetic disorder in cortex and medulla of both kidneys caused by repeated cell
division
• Expansion cause dead to normal renal tissue
• Symptoms appear as the cyst grow
– Hematuria, c/o low back pain, headache, UTI, kidney stones
– Enlarged girth, CVA tenderness
• Progresses to ESRD in 50% of pts by age of 60 yrs
• Complication - severe hypertension, UTIs, heart valve disorders, high risk
aneurysms of aorta or cerebral circulation, liver cyst
From book: It is caused by an autosomal-recessive disorder (ARPKD), and its course is
rapid and progressive, leading to severe lung and liver dysfunction and end-stage renal
disease (ESRD), causing death during infancy or childhood. The adult form is autosomal-
dominant polycystic kidney disease (ADPKD).

• Medical Mgt & Treatment

– Dx made on clinical manjfestations
– Definitive dx MRI & ultrasound, IVP or CAT scan
– Look for cyst on other organs
– Tx similar to ESRD –hemo dialysis and peritoneal dialysis
– Mgt pain and hypertension mgt with ACE inhibitors or ARB
– Severe pain may require nephrectomy
 – Antibiotics mgt infections
– Renal transplant may cure
– Lifestyle changes – diet, exercise & smoking cessation
• Nursing Mgt/interventions
– Diet modification; low K, phosphorus, protein and Na
– Fluid restrictions to prevent FVE and heart failure
– Antihypertensive as ordered
– Antibiotics as ordered
– Pain medications
– VS mgt, daily wts, oxygenation (< O2 sats)
– Monitoring of lab values, H&H, BUN, Creatinine, Na, K, Ca, phosphorus,
urinalysis & culture
• Teaching
– Signs and symptoms infection
– Prescribed dietary restrictions
– Medications prescribed for BP, infection, etc
– Safety measure , i.e. falls

*Pyelonephritis
• Most common renal disease
• Young women most often affected reflecting sexual activities in the age group
• Major risk factor multiple preexisting UTIs, treated or untreated
• Bacterial infection in the kidney and renal pelvis
• Organisms move up from the urinary tract into kidney tissue
– Escherichia coli is the most common cause
• Involves acute tissue inflammation, tubular cell necrosis, and possible abscess
formation
• Filtration, reabsorption, and secretion are impaired and kidney function is reduced
• Diagnosed similar to cystitis, but with use of KUB and C-reactive protein and ESR
• Can be acute or chronic
Page 1524 – REVIEW NURSING INTERVENTIONS
• Acute
– Active bacterial infection
– Caused by bacteria with or without obstruction or reflux
– S/S
– Fever, chills, tachycardia, tachypnea, flank pain, tender CVA angle,
abdominal discomfort, nausea, vomiting, fatigue, nocturia, recent treatment
of UTI, burning, urgency or frequency with urination
• Chronic
– Results from repeated or continued upper urinary tract infections or the
effects of such infections
– Occurs with structural deformities, urinary stasis, obstruction, or reflux
– S/S:
– Can be related to infection or reduced kidney function
 – Hypertension, inability to conserve sodium, decreased urine-concentrating
ability → nocturia, tendency for hyperkalemia and acidosis

Management and Treatment

• Drug therapy with antibiotics
– Review medications pg 1444
– Ensure client takes full course and understands therapy
– Based on urine c/s
• Supportive Interventions
– Cranberry Juice prevents sticking of bacteria to urinary tract structures
• Nutrition therapy
– Increase fluid intake to 2-3 L
– Ensure adequate caloric intake
• Surgical Management
– Pyelolithotomy (stone removal from kidney)
– Nephrectomy (removal of kidney) → last resort
– Ureteral diversion
– Reimplantation of ureter to restore proper bladder drainage
• Prevention of ESRD
• Education on treatment and prevention of complications

• *Glomerulonephritis - REVIEW NURSING ACTIONS/ASSESSMENT

• An inflammatory reaction in the glomerulus with a collection of immune complexes
(antigens and antibodies)
• Most commonly due to reaction to B-strep
• Complex becomes trapped in glomerulus and decreases GFR
• Third leading cause of kidney failure in USA
• Many infectious causes
• Clinical manifestation are present because of damage to Glomerulus basement
membrane (GBM)
• Can be acute or chronic